Frequently Asked Questions

As we explained in the January 4, 2018 letter, only those items provided in the Medicaid program on a fee-for-service (FFS) basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the FFP limitation. If a state is 90% managed care the state would only have to show compliance or a demonstration with the 10% of FFS utilization and expenditures for the relevant DME items.

FAQ ID:93531

So long as the MCOs are not paid on a fee-for-service (FFS) basis, MCOs are not covered under this statute or subject to the limit on FFP. Only the relevant DME items provided in FFS are included in this limit.

FAQ ID:93536

Only those items provided in the Medicaid program on a fee-for-service basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the federal financial participation limitation.

FAQ ID:93541

If the HCBS waiver includes FFS payments for DME, the state’s expenditures for DME would be subject to the limit.

FAQ ID:93546

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

No, if a state's payment methodology describes payment at no more than 100 percent of the Medicare rate for the period covered by the UPL then it does not need to submit a demonstration using the template(s). To show the state has met the annual UPL demonstration reporting requirement it should make CMS aware that it is paying no more than the Medicare rate.

FAQ ID:92201

States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.

FAQ ID:92251

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

Many Medicaid beneficiaries living with dementia and other conditions can have a heightened risk of wandering, or attempting to leave a setting (exit-seeking) unsafely. These behaviors are not necessarily constant or permanent.

Wandering occurs in ways that may appear aimless but often have purpose. People may wander simply because they want to move. Sometimes wandering responds to an unmet basic need like human contact, hunger, or thirst; a noisy or confusing environment; or because people are experiencing some type of distress, like pain or the need to use the toilet. Wandering can be helpful or dangerous, depending on the situation. Although people who wander may gain social contact, exercise, and stimulation, they can also become lost or exhausted.

Person-centered planning, staff training and care delivery are core components of provider operations to meet HCBS requirements while responding to unsafe wandering and exit-seeking behavior in an individualized manner.3 Person-centered services involve knowing individuals, and their conditions, needs, and history and using this knowledge to create strategies to assure that individuals are free to interact with others and the community in the most integrated way possible and still prevent injury for those who wander or exit-seek unsafely. Home and community-based settings must demonstrate that person-centered planning drives their operations and services for each person. The beneficiaries the settings serve must drive the person-centered planning process with assistance from a trained, competent, assessor, care manager or similar facilitator. The beneficiary should be able to get input from people who are important to him or her, while still reflecting the individual's input as much as possible. Person-centered plans and related decisions should be consistent with the person's needs and preferences, and informed by family members, caregivers, and other individuals that the beneficiary has identified as playing an important role in his or her life. The role of person-centered planning and the process for realizing this role is described in the final HCBS regulation and in guidance found on the Medicaid.gov website.

Person-centered service plans should be developed with the individual, and include their representatives as appropriate. The person-centered planning process should include a process that:

• is informed by discussions with family members or other individuals who are important to them about key aspects of daily routines and rituals;
• focuses on an individual's strengths and interests;
• outlines the individual's reaction to various communication styles;
• identifies the individual's favorite things to do and experience during the day, as well as experiences that contribute to a bad day;
• proposes experiences that the person may enjoy as community engagement, and describes those factors or characteristics that the individuals would find most isolating or stigmatizing

To promote effective communication, which is at the core of person-centered planning and service delivery, provider staff serving beneficiaries who wander or exit-seek should receive education and training about how to communicate with individuals living with conditions that may lead to unsafe wandering or exit-seeking. Training programs may include important information on issues such as:

• The most common types of conditions, diseases and disorders that lead to wandering behavior; the various stages of key conditions that result in increased risk of wandering and what to expect over time; and the potential impact of these conditions on the individual's ability to function.
• Differentiating between most common types of conditions, diseases and disorders that lead to wandering behavior from serious mental illness or adverse environmental conditions such as overmedication or neglect.
• Assessing individuals for co-occurring conditions (including barriers to sufficient adaptive skills and the ability to communicate with others) that increase risk for unsafe wandering or exit-seeking.
• Understanding situations that led to past instances of unsafe wandering or exit-seeking or the desire to engage in them;
• Principles of person-centered care planning and service delivery;
• Strategies for identifying and handling behavioral expressions of need or distress.

In addition to previous guidance provided by CMS on the implementation of person-centered planning requirements outlined in the federal HCBS regulations defining home and community-based settings, integration of the following promising practices around person-centered planning specifically for people who wander or exit-seek unsafely is recommended:

• Assessing the patterns, frequency, and triggers for unsafe wandering or exit-seeking through direct observation and by talking with the person exhibiting such behaviors, and, when appropriate, their families.
• Using this baseline information to develop a person-centered plan to address unsafe wandering or exit-seeking, implementing the plan, and measuring its impact.
• Using periodic assessments to update information about an individual's unsafe wandering or exit-seeking, and adjust the person-centered plan as necessary.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)

FAQ ID:94926