Frequently Asked Questions

State Medicaid Director Letter #17-004 addressed this area by stating: “Reductions necessary to implement CMS federal Medicaid payment requirements (e.g., federal upper payment limits and financial participation limits), but only in circumstances under which the state is not exercising discretion as to how the requirement is implemented in rates. For example, if the federal statute or regulation imposes an aggregate upper payment limit that requires the state to reduce provider payments, the state should consider the impact of the payment reduction on access.” In addition, the long-standing policy of the Medicaid program has been that Medicare rates are sufficient to ensure access.

FAQ ID:93521

We acknowledge that there are differences between the Medicare and Medicaid populations, but nothing in the policy guidance or statute compels states to reduce the items that states provide to people with disabilities under the state plan. As noted above, the statute does not expressly compel states to reduce the payment rates for DME. The statute limits the amount of money that the federal government will pay (i.e., FFP) for the relevant DME in the aggregate as compared with the relevant DME provided in the Medicare program. States retain the flexibility to make payments at rates that best serve the needs of their Medicaid beneficiaries.

FAQ ID:93526

Given the scope of the coverage changes that states and the federal government will be implementing on January 1, 2014, and the value of building on the experience that will be gained from those changes, HHS expects to issue proposed rules regarding the Basic Health Program for comment in 2013 and final guidance in 2014, so that the program will be operational beginning in 2015 for states interested in pursuing this option.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)

FAQ ID:92141

HHS is working with states that are interested in the concepts included in the Basic Health Program option to identify similar flexibilities to design coverage systems for 2014, such as continuity of coverage as individuals' income changes. Specifically, we have outlined options to states related to using Medicaid funds to purchase coverage through a Qualified Health Plan (QHP) on the Marketplace for Medicaid beneficiaries (PDF, 242.79 KB). Additionally, some states with current Medicaid adult coverage expansions are considering offering additional types of assistance with premiums to individuals who will be enrolled in QHPs through the Marketplace. HHS will review all such ideas.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)

FAQ ID:92146

Regulation at 42 CFR 447.000(c)(1) and (2) specifies Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, or their successor codes.

FAQ ID:92126

The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.

FAQ ID:92231

The Notes tab should include any and all information to fully support the state's UPL demonstration. CMS expects states to provide clarifying information in the Notes tab. For example, this information would provide details for the adjustments to Medicare as input in variables 212.1 and 212.2, various supplemental payments in variables 313.1, 313.2, and 313.3, and adjustments to Medicaid in variables 314.1 and 314.2. In addition to reporting through the notes tab, the state also has the option of using the guidance document or narrative to fully support its UPL demonstration.

FAQ ID:92376

The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92106

Technical assistance questions, as well as information about state Medicaid prevention efforts, can be directed to: MedicaidCHIPPrevention@cms.hhs.gov and/or Deirdra Stockmann, 410-786-2433.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91501

Any retroactive payments made to providers in order to ensure that eligible providers receive the applicable Medicare rate for eligible services will not be considered claims subject to the requirements in 42 CFR 447.46.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:91411