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Frequently Asked Questions

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.

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Under 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

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Under 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

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The 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

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As 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

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Will HHS issue federal guidance and regulation regarding implementation of the Basic Health Plan?

Yes. HHS plans to issue guidance on the Basic Health Plan in the future. States interested in this option should continue to talk to HHS about their specific questions related to the implementation of the Basic Health Plan.

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FAQ ID:94496

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