Frequently Asked Questions

To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.

FAQ ID:91086

States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.

FAQ ID:91091

Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.

FAQ ID:91096

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

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

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

No. States continue to have the option to cover children above 133 percent of the FPL either under a Medicaid expansion or separate program. States must maintain CHIP "eligibility standards, methodologies, and procedures" for children that are no more restrictive than those in effect on March 23, 2010 as specified under the "maintenance of effort" provision at 2105(d)(3) of the Act. A parallel requirement in Medicaid can be found at sections 1902(a)(74) and 1902(gg) of the Act. These provisions are effective through September 30, 2019.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92621

Yes. The CHIP enhanced FMAP will continue to be available for children whose income is greater than the Medicaid applicable income level (defined in section 457.301 and based on the 1997 Medicaid income standard for children) after these children transition to Medicaid. This includes children who previously qualified for CHIP in a separate program and uninsured children whose family incomes are up to 133 percent of the Federal poverty level, and therefore will be eligible for Medicaid in 2014. Regular Medicaid matching rates will apply for all other children covered under the mandatory group for children aged 6-18-children with income no more than 100 percent FPL and insured children with income above 100 percent to 133 percent FPL.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92626

Yes. States that are transitioning children from a separate CHIP to the Medicaid state plan under the mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act (which will be part of the newly consolidated mandatory group for children at 42 CFR 435.118), will need to submit both a Medicaid and CHIP SPA. The Medicaid SPA will need to be approved prior to, or simultaneously with, the CHIP SPA.

In addition, states that currently cover uninsured children aged 6-18 with income above 100 percent to 133 percent FPL under the Medicaid eligibility group for optional targeted lowincome children at section 1902(a)(10)(A)(ii)(XIV) of the Act (42 CFR 435.229) will need a Medicaid SPA to transition these children to the mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act under the mandatory children's consolidated group at 42 CFR 435.118 and must expand their coverage to include insured children.

The SPA templates are available at http://www.medicaid.gov/State-Resource-Center/Medicaidand-CHIP-Program-Portal/Medicaid-and-CHIP-Program-Portal.html and CMS is available to provide technical assistance to states as they work through this transition.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92631

In order to ensure a smooth transition of children from a separate CHIP to Medicaid state plan coverage, we encourage states to consider the following points as they prepare for this transition. CMS will work with states on these issues as part of the CHIP SPA review process:

• Proper and timely notification to families, including detailed information on changes related to managed care plans, providers, benefits and cost sharing and what families can expect and need to do in preparation for the transition.
• Education and notification to key stakeholders, including providers, managed care plans, and carve outs, such as mental health or dental services.
• Establishment of a help line to address questions from families during the transition.
• Continuity of care for children in treatment, such as the transfer of prior authorization requests from CHIP to Medicaid providers.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92636