Frequently Asked Questions

The federal financial participation (FFP) limitation imposed by section 1903(i)(27) of the Act applies only with respect to those items of durable medical equipment (DME) covered by a state’s Medicaid program that are also covered by Medicare. Items covered as DME by only one of the programs are not included. This statutory limitation also does not apply to items for which Medicaid is not the primary payer. The statute refers to state expenditures for DME, therefore all funds expended by the state Medicaid agency on purchasing the relevant DME items and for which the state is requesting federal matching funds needs to be accounted for in the demonstration. CMS suggests taking the entire amount spent on a certain DME item (i.e., per Healthcare Common Procedure Coding System code) and divide it by the total volume to get an average price per DME item for the purpose of the calculation tool. If states have specific questions please contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.

FAQ ID:93576

Yes. To the extent that Medicare classifies such items as DME equipment and such items are covered by Medicare, they are included in the FFP limit in the statute. Oxygen supplies are included in the DME limit on FFP according the Medicare definition on DME.

FAQ ID:93581

States have the flexibility to conduct their own analysis and use their own calculation tool to show compliance to the statute. CMS has received approval through the paperwork reduction act to have the calculation tool collection of information be used for ease of administration for states in their durable medical equipment federal financial participation limit demonstration reporting and analysis. CMS asks states not using the calculation tool to contact the resource mailbox: MedicaidDME@cms.hhs.gov.

FAQ ID:93586

For purposes of the federal financial participation (FFP) limit, Medicare claims volume will not be considered in the demonstration of the limit. Only Medicaid claims volume is relevant for the calculation of the FFP limit.

FAQ ID:93591

The Centers for Medicare & Medicaid Services (CMS) will analyze state data provided to CMS and return the detailed information comparing the data sent from the state to the lowest and average Medicare rates for the relevant DME in the state on the aggregate. CMS will work with states during 2018 to assist with reporting necessary information under the new statute, and will run data reports for states before the end of the year if requested. A state that wishes this review should contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.

FAQ ID:93596

States are not required to change how they pay for items because of the statute. If a Medicaid program only purchases Medicare capped rental items, then that is the payment and utilization we will compare to Medicare’s rates in determining the aggregate expenditures. States are not obligated to alter their coverage of durable medical equipment due to the statute.

FAQ ID:93601

For the aggregate demonstration of Medicaid expenditures, we intend to use the Medicare rates released for services on or after January 1 of each year. We would suggest that states setting their rates according to Medicare rates in the state plan would follow a similar practice. States are, of course, welcome to use the quarterly updates of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) if that’s their intention, but we are not requiring those rate updates beyond the January 1 DMEPOS update.

FAQ ID:93606

When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.

FAQ ID:92221

CMS regulations at 42 CFR 435.603(f)(2) provide that the parents would be included in the child's household in this situation. However, if the parents do not intend to continue to claim the child as a tax dependent for the following tax year, states may alternatively use the option provided at 435.603(h)(3) to consider the child's move to the live with another caretaker relative as a "reasonably predictable change in income" and apply the non-filer rules to the child at 435.603(f)(3). Under the non-filer rules, neither the parents nor the caretaker with whom the child is living would be included in the child's household for purposes of Medicaid and CHIP eligibility.

Note that to be claimed as a "qualifying child," children generally must live with their parents for at least half of the year (certain exceptions apply), but parents may also be able to continue to claim a child as a "qualifying relative." States are not expected to determine whether or not a parent is permitted to claim their child as a tax dependent or not, but states may wish to consult IRS Publication 501 to better understand the general requirements which must be met for a tax filer to claim another individual either as a "qualifying child" or "qualifying relative." IRS Publication 501 can be accessed at the following link: http://www.irs.gov/pub/irs-pdf/p501.pdf.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92571

For purposes of eligibility for coverage through the Marketplace, the Affordable Care Act defines Indians as individuals who are members of a federally recognized Indian Tribe. The definition of Indian currently in use for Medicaid beneficiaries follows a broader definition that includes descendants of Indians and all American Indians and Alaska Natives. As a result, American Indians and Alaska Natives who are not members of an Indian tribe would not be eligible for exemptions available through an Exchange, including from individual responsibility payments, qualification for special monthly enrollment periods and cost-sharing reductions.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92576