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.
Frequently Asked Questions
Are states only required to conduct Upper Payment Limit (UPL) demonstrations for services with approved state plan supplemental payment methodologies?
No, an upper payment limit demonstration considers all Medicaid payments (base and supplemental). States must conduct UPL demonstrations for the applicable services described in State Medicaid Director Letter (SMDL) 13-003 regardless of whether a state makes supplemental payments under the Medicaid state plan for the services.
FAQ ID:92191
SHARE URLFor our Nursing Facility (NF) Upper Payment Limit (UPL) calculation we separate Medicaid allowable costs into three categories: salaries and benefits, operating costs, and property costs. Based on previous guidance from CMS, we do not apply an inflation factor to the property costs. In looking at the template, it appears the inflation factor is applied to all costs. Is this correct?
Where inflation is not applied to property costs, please separate out this cost from the Medicare UPL by reporting these amounts in variable 402 - Adjustment to the Medicare UPL.
FAQ ID:92361
SHARE URLAre states required to use the Outpatient Hospital Serves (OPH) Upper Payment Limit (UPL) template to demonstrate the clinical diagnostic laboratory (CDL) services UPL?
No, the template does not include variables to report clinical diagnostic laboratory services.
FAQ ID:92371
SHARE URLBased on CMS guidance, states may take up to 18 months to bring an IV&V contractor on board to perform certification tasks or align current IV&V contract to comply with CMS guidance pertaining to scope of services and financial independence. What must the state do if the IV&V contractor's start up is delayed?
IV&V contractor activities must still be performed such as checklist evaluation, artifact review and preparation of IV&V Progress Reports. The state should provide a plan and timeline for how these activities will be supported and performed until the proper IV&V contract can be either procured or aligned with updated CMS guidance on IV&V.
FAQ ID:94866
SHARE URLIs IV&V required during operations and maintenance (O&M) for MMIS?
As contained in the MECT standard RFP/contract language required by CMS, CMS does not cover activities that the state may require of the IV&V contractor during ongoing O&M. However, as Medicaid is moving away from monolithic single applications, it is expected that states will continuously update and replace modules in their enterprise. Therefore, IV&V should always have a role to ensure successful integration and testing.
FAQ ID:94881
SHARE URLWhat would preclude a company from being eligible to bid on the MMIS or E&E IV&V contract(s)?
If an organization is performing another role (such as systems integrator, PMO, quality assurance, etc.) on the MMIS or E&E project, it may not perform the IV&V function on the same project. A state may contract the same vendor to perform the IV&V role for both its E&E and MMIS projects.
FAQ ID:94886
SHARE URLWhy does the IV&V contractor need to sit outside the Medicaid agency?
To reduce potential conflict of interest, CMS is ensuring that states are arranging IV&V services through contracts that should be owned outside of the agency that owns the MMIS or E&E project. The oversight organization for the IV&V contractor should not be involved in oversight of the development effort, a stakeholder in the business implementation, or the DDI contractor. The IV&V contract monitor should be aware of system development problem solving, reporting, and contractor management. This contract oversight provides true independence between the IV&V contractor and system development teams. This requirement is consistent with other HHS agencies' practices and industry best practices.
FAQ ID:94891
SHARE URLHow does section 2001(a)(5)(B) of the Affordable Care Act impact states currently covering children 6-18 up to 133 percent of the FPL under a separate CHIP?
Section 2001(a)(5)(B) of the Affordable Care Act (implemented through regulations for the Medicaid program at section 435.118) increased the minimum income limit applicable to Medicaid eligibility for the mandatory group for poverty-level related children aged 6-18 from 100 to 133 percent of the FPL under section 1902(a)(10)(A)(i)(VII) of the Act. Therefore, if a state is currently covering uninsured children up to 133 percent of the FPL under a separate CHIP, these children must be transitioned to the Medicaid state plan under this children's group effective January 1, 2014. CMS is available to work with states individually on their transition plans for this population.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92606
SHARE URLAre these children who are being transferred from CHIP to the Medicaid state plan considered optional targeted low-income children under section 1902(a)(10)(A)(ii)(XIV) of the Act?
No. For the purposes of eligibility, these children are considered a mandatory Medicaid group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act. As described below, states will continue to receive the CHIP matching rate for this population.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92611
SHARE URLWill new applicants/children ages 6-18 with incomes between 100 and 133 percent of the FPL with other health insurance qualify for coverage under the Medicaid state plan?
Yes. Under the Medicaid mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act, insured children must be covered in addition to uninsured children (please also see applicable match rate questions below). This is different from the rules governing a separate CHIP program, which preclude coverage for insured children.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92616
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