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

If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.

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

FAQ ID:92121

When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.

FAQ ID:92221

The state should report the expected amount of supplemental payments to be made during the period covered by the UPL demonstration. Supplemental payments should be entered into variables 303.1, 303.2, and 303.3 for the Inpatient Hospital and Outpatient Hospital templates and 313.1, 313.2, and 313.3 for the Nursing Facility templates. The state should provide detail in the notes tab on the types of supplemental payments and the related dollar amount of each payment.

FAQ ID:92291

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

In order to receive the one percentage point FMAP increase, the state is required to submit a SPA with updated coverage pages. When a SPA is submitted with updated coverage pages, we will perform a review of the corresponding payment page(s). A state does not need to submit a SPA with revised payment pages, and conduct public notice, unless it wishes either to begin coverage and payment for these services or to change the existing payment rates (in other words, if the state already pays for the preventive services in some contexts, a payment SPA may not be needed if the state does not want to change the existing payment rate or methodology).

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

FAQ ID:91516

The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.

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

FAQ ID:91521

A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit. To claim that enhanced FMAP for managed care payments, CMS must review the methodology that the state intends to use to estimate the value of the preventive services benefit in its capitation rates.

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

FAQ ID:91526

Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.

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

FAQ ID:91531