Frequently Asked Questions

In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.

FAQ ID:92446

Applicants that indicate they have a disability, need long-term care or are over age 65 are always referred to the Medicaid agency for a determination on a non-MAGI basis, regardless of income and household composition, since the FFM is evaluating eligibility for MAGI-based eligibility groups only. Additionally, applicants may always request a full Medicaid determination at the end of the application process. In assessment states, the Medicaid agency will do a final determination of eligibility for these applicants, whereas in determination states, the Medicaid agency just needs to follow up for a non-MAGI determination. The expanded flat file will contain a specific indicator showing if the applicant requested a full determination.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 198.3 KB)

FAQ ID:92136

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

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

We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 198.3 KB)

FAQ ID:91906

If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 198.3 KB)

FAQ ID:91921

In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 198.3 KB)

FAQ ID:91926

Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 198.3 KB)

FAQ ID:91931