Frequently Asked Questions

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.

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• 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.

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

FAQ ID:92146

Yes, services covered under the state plan rendered during the PE period will qualify for federal match regardless of the ultimate Medicaid eligibility decision. The standards that states can set for hospitals and the findings from reviews of hospital performance relative to those standards are intended to ensure that hospitals are making appropriate PE determinations and following state hospital PE procedures. When problems are identified, states should take corrective action to ensure future compliance with state policies and procedures.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:92111

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

When a Medicare provider number is not available, such as for some nursing facilities, the state should populate variable 112 using the acronym NMC, which stands for "Not Medicare Certified". Adding this information will help to clearly identify the facility's status.

FAQ ID:92286

Section 1903(i)(7) of the Social Security Act specifies a separate UPL for CDL services which limits payment to no more than the Medicare rate on a per test basis. To meet the statutory provision, the UPL for CDL services must be separately demonstrated from the OPH services UPL. States do not have the ability to "borrow room" from the CDL UPL and apply it to the OPH UPL.

FAQ ID:92401

Yes, in order to ensure that hospitals comply with the agreement to make presumptive eligibility determinations consistent with state policies and procedures, states have the flexibility to require hospitals to have the staff that will do PE determinations take and pass knowledge tests in order to make PE determinations. Since the PE enrollment process does not require detailed knowledge of Medicaid eligibility policy, the test should be appropriately geared to the information needed to make an appropriate decision and comply with state procedures.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91691

The use of the two performance metrics CMS described in the final rule at section 435.1110 (the proportion of individuals determined PE who submit a full application and the proportion of those who submit an application who are deemed to be Medicaid eligible) is optional for states. States may choose to use other or additional metrics in their hospital PE programs. All states should collect data on hospital performance to fulfill their oversight responsibilities.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91696

States are considering a number of different types of performance standards, including the proportion of hospital PE determinations made in an outpatient setting (given that a strong incentive exists for determinations in inpatient settings but it is desirable to also implement PE for outpatients to ensure reaching as broad a population as possible) and the number of hospital PE applications completed in one month. Other states are collecting baseline data in order to measure hospital performance and plan to establish specific standards at a later point.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91701

While individuals may be determined "presumptively eligible" for coverage under the new adult group by a qualified hospital or qualified entity, the newly eligible FMAP is only available once the full eligibility determination has been completed. In these circumstances, the newly eligible FMAP is only authorized with respect to individuals determined eligible for the new adult group by the state agency or other public entity authorized to make final Medicaid eligibility determinations. The regular FMAP applies until such time as the state (or other authorized entity) determines an individual to be eligible for the new adult group and the state confirms that they also meet the definition of a "newly eligible individual."

As noted in our August 2013 FAQs, in appropriate circumstances, a state may retroactively adjust claiming for services provided during a presumptive eligibility period. Specifically, newly eligible status is available based on the effective date of eligibility for the new adult group, which may be as early as the third month prior to the month that the individual applied for Medicaid in accordance with 42 CFR section 435.914 (re-designated at section 435.915 under the March 2012 final eligibility rule), provided that the individual would have been eligible for Medicaid had he or she applied as of the earlier date. To the extent to which the presumptive eligibility period is encompassed within such retroactive eligibility period and the state determines that the individual meets the criteria for newly eligible status, the state may retroactively adjust claiming for services provided during a presumptive eligibility period. The state is not required to make such a retroactive adjustment if the state determines that an adjustment would be administratively burdensome.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91706