Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
In our state, the Medicaid agency instructs Rural Health Centers (RHCs) to bill the Medicaid agency for the administration of a Vaccines for Children Program (VFC) immunization by using the provider's individual provider number for each immunization administration and the RHC/Medicaid group number for payment to the RHC for other medical services. Under the CMS 2370-F rule, do RHC's not qualify for enhanced payments on E&M codes billed with the RHC Medicaid facility provider number, but the individual providers do qualify for enhanced payment on VFC administration? Given that my state also requires RHCs to bill for E&M hospital codes such as 99221 or 99223 by using the individual treating provider's number, shouldn't the individual providers be "qualifying" providers for the purpose of enhanced payments for these hospital codes?
Providers such as RHCs and Federally Qualified Health Centers (FQHCs) are reimbursed on the basis of an all-inclusive rate under their own Medicaid benefit categories. As specified in the final regulation, only services provided under the physician benefit and billed using a physician fee schedule are eligible for higher payment. In your examples, since the state reimburses the vaccine administration and the hospital codes on a fee-for-service basis and does not pay then all-inclusive rate, those services would be eligible for higher payment if the physician who provides them properly self attests to eligibility. However, services provided by the physician that are reimbursed through the all-inclusive rate would not be eligible.
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FAQ ID:93901
SHARE URLUnder CMS 2370-F, we interpret 42 CFR 447.205 to not require public notice of a state's implementation of section 1202 of the ACA because "the change is being made to conform to Medicare methods or levels of reimbursement". Does CMS interpret this regulation differently?
CMS agrees that 42 CFR 447.205(b)(1) excepts states from the public notice requirements when a change is being made to conform to Medicare reimbursement. However, states must still ensure that providers are properly notified of the requirements for self-attestation and higher payment through provider bulletins or other mechanisms.
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FAQ ID:93906
SHARE URLUnder CMS 2370-F, are the services of "physician extenders" (defined as physicians who provide services in support of eligible physicians) eligible for higher payment when an eligible primary care specialist bills for their services? Examples of "physician extenders" include neurologists, OB/GYNs, pathologists, anesthesiologists and surgeons who provide services to the patients of eligible physicians.
No. The only services that qualify are those provided directly by physicians (or by non-physician practitioners that they supervise) who self-attest to an eligible primary care designation and whose attestation is supported by evidence of board certification or claims history. Physicians who do not qualify on their own merits cannot receive higher payment by having an eligible physician bill on their behalf. As previously noted, physicians must accept professional responsibility/liability for the services provided by non-physician practitioners under their supervision.
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FAQ ID:93911
SHARE URLUnder CMS 2370-F, are eligible E&M and vaccination codes that are covered by managed care health plans but not under the Medicaid state plan eligible for reimbursement at the enhanced Medicare rate?
No. The only codes that are eligible for reimbursement at the Medicare rate as specified under the final rule are those eligible codes that are identified under the Medicaid state plan. Additional E&M or vaccination administration codes that are being “covered” by a health plan but that are not identified in the state plan cannot be reflected in the rates.
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FAQ ID:93916
SHARE URLThe CMS 2370-F final rule specified that states will need to recoup the enhanced payments made to non-eligible providers identified through the annual statistically valid sample. Must health plans follow the same procedure for non-eligible providers
States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in some states, this sample will include both fee-for-service (FFS) and managed care providers.
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FAQ ID:93921
SHARE URLAs we are working to implement ACA 1202, we found that we have to pay to access the American Board of Medical Specialties (ABMS) website because use of the website for business or certification is strictly prohibited. Is CMS aware of what other states are doing? Is there some other way to access this information without paying?
The state has two options: (1) it may claim this cost as an administrative expense of the Medicaid program; or, (2) it may require physicians to provide this documentation when they self-attest.
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FAQ ID:93926
SHARE URLWhat methods can states use to execute conversion to modified adjusted gross income (MAGI) as required by the Affordable Care Act?
Effective January 1, 2014, MAGI eligibility rules will be used to determine eligibility for nonelderly, nondisabled eligibility groups. The transition to MAGI also involves converting current net income eligibility standards to MAGI standards. MAGI rules apply regardless of whether a state adopts the new adult eligibility group. The December 28, 2012 Modified Adjusted Gross Income (MAGI) conversion guidance (PDF, 177.59 KB) sets out options for a state to use a standardized MAGI conversion methodology (using Survey of Income and Program Participation (SIPP) data or with state data) or to propose an alternative methodology for converting to MAGI.
There are two potential ways of using the standardized MAGI conversion methodology:
- States may choose to have CMS calculate the converted income levels for eligibility groups requiring conversion using state-adjusted data from the Census Bureau's SIPP; or
- States may choose to use their own data as the source for applying the standardized conversion methodology.
For each eligibility group income level that needs to be converted, under the standardized MAGI conversion methodology, individuals whose net income is within 25 percentage points of the FPL below the current income standards will be selected (for example, if the current standard is 80 percent of the FPL, the analysis will include people with incomes between 55 and 80 percent FPL). The next step is to calculate disregards as a percent of FPL for each selected individual. The resulting average disregard amount as a percent of FPL is added to the current net income standard to get the converted standard.
For example, if the average disregard is 8 percent FPL, the converted standard would be 88 percent FPL. This basic process is the same regardless of whether SIPP data or state data is used.
Alternatively, states have the option to propose their own method, subject to approval by CMS. States are asked to provide a statement of intent by February 15, 2013 and must submit their MAGI conversion plans by April 30.
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FAQ ID:93931
SHARE URLWhat issues should states consider in choosing which MAGI conversion method and data source to use?
Factors that states might want to consider in choosing an income conversion method and data source include whether the state currently maintains or can easily access the data that are needed to do the conversions, as well as the quality and completeness of the state's data. In addition, states will want to consider whether they have the analytical resources needed to do the conversions with their own data, how long it would take them to run the conversions and how much it would cost to pay a contractor to do the analysis. Finally, states should also consider preferences about using state-adjusted SIPP or state data.
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FAQ ID:93936
SHARE URLIf a state wants to use the Standardized MAGI Conversion Methodology with its own date, what data elements will it need to use?
Detailed information on how to use state data to apply the standardized conversion methodology is forthcoming, but in general states will need 1) information on net income of each person and the size of the Medicaid eligibility unit to establish which enrollees fall within the 25 percentage point band below the current net income standard; and 2) data on the total amount of disregards for each individual within the 25 percentage point band - if this is not stored as a data element in the state's system, this can be calculated by adding up individual disregards, or as the difference between gross income and net income.
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FAQ ID:93941
SHARE URLWhat type of technical assistance is available to states on MAGI Conversion?
Technical assistance for states thinking through their MAGI conversion options is available through the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota. SHADAC is available to help states understand the income conversion methods, the data sources that can be used (SIPP or state data), and factors for states to consider in choosing a methodology. CMS will do conversions for all states using the standardized conversion methodology with SIPP data. States that choose to use state data or that propose a different methodology will need to do the conversions themselves, and SHADAC is available to provide consultation with states as they work through the process. This help is available at no cost to states. States can contact SHADAC for help with income conversion at (612) 486-2439 or by emailing their questions to fmaphelp@shadac.org.
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FAQ ID:93946
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