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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 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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Are the coverage expansions for children specified under the Affordable Care Act optional for states?

No. The extension of Medicaid coverage to the new group of former foster care children up to age 26 (see section 1902(a)(10)(A)(i)(IX)) and to all children age six and older with incomes up to 133 percent of the (FPL) (1902(a)(10)(A)(i)(VII) are required by the Affordable Care Act and were not affected by the Supreme Court's decision. The Medicaid eligibility change for older children eliminates the confusing "stair step" federal eligibility rules that have put low-income children in the same family in different programs depending on their age. As previously indicated in our Medicaid and CHIP eligibility final rule, the CHIP enhanced matching rate will continue to be available for children transferring from separate CHIP programs to Medicaid as a result of eligibility changes in the Affordable Care Act.

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FAQ ID:94096

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