Affordable Care Act Enrollment

Effective January 1, 2013, Texas Medicaid is complying with the provisions of section 6401 of the Affordable Care Act of 2010 (ACA) affecting the enrollment of Texas Medicaid providers. All Medicaid providers will be required to re-enroll in Texas Medicaid and to do so every three to five years per the risk category from Texas Medicaid. There will be an application fee at initial enrollment and re-enrollment unless that fee has already been paid for an application with their Medicare enrollment. All institutional providers are required to pay the application fee.

There is no application fee for: a group practice; physician, non-physician practitioner; and outpatient physical therapy/occupational therapy/speech pathology service providers that enroll via the CMS-855B.

Providers are categorized by their risk level of fraud, waste and abuse which determines their required screening elements. CMS and HHSC are responsible for the risk category assigned to a provider:

These providers are assigned as Limited Risk providers: physicians, non-physician practitioners; medical groups and clinics; ambulatory surgical centers (ASCs); audiologists; federally qualified health centers (FQHCs); hospitals, including critical access hospitals; end stage renal disease facilities; occupational therapists enrolling as individuals or as group practices; pharmacies; radiation therapy centers, rural health clinics (RHCs); skilled nursing facilities; and speech language pathologists.

The limited risk category required screening elements are verification of provider-specific requirements, including but not limited to the following:
• License Verification
• National Provider Identifier (NPI) verification
• Federal and state database checks
• Ownership/controlling interest information verification

Beginning January 1, 2013, all providers must re-enroll at least every five years. Suppliers of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) are required to re-enroll at least every three years. HHSC may require certain providers to re-enroll more frequently.

HHSC, through correspondence from TMHP, will notify providers when they are to submit their re-enrollment applications. Do not submit anything until they tell you to.

HHSC says they will work through health care professional associations, the providers themselves, and through the managed care Medicaid HMOs to notify providers as to when each provider will need to submit their Texas Medicaid re-enrollment applications

The Texas Health and Human Services Commission (HHSC) has posted a Frequently Asked Questions (FAQ) to the TMHP website.

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