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
Federally qualified health centers (FQHCs)/ rural health clinics (RHCs) which receive an encounter rate are excluded under the rule for CMS-2370 F. Are FQHCs/RHCs who are paid provider fee-for-service included in the increase?
FQHCs and RHCs are required by law to be paid at least prospective payment system (PPS) for core primary care services. Physician services are core FQHC and RHC services and, therefore, should not be reimbursed on a fee-for-service basis.
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FAQ ID:92701
SHARE URLIn our state, advanced practice nurses must have a collaborative practice agreement with a physician within 50 miles of their office. Under the collaborative practice agreement, a physician must review a certain percentage of the nurse's patient charts every 2 weeks. Such nurses bill independently using their own Medicaid number. Is the collaborative practice agreement enough documentation for an advance practice nurse, with at least 60 percent of services billed by the nurse for calendar year (CY) 2012 for
Increased payment is available for services provided by eligible physicians or for services provided under their personal supervision. This means that the physician accepts professional responsibility (and legal liability) for the services provided. It does not appear that the collaborative arrangement requires that the physician accept professional responsibility for each of the services provided by the nurses. Therefore, increased payment would not be available.
However, if the physician is required to accept professional responsibility for the services provided by the advanced practice nurses and the physician is eligible based on self-attestation to a specified primary care specialty designation supported by either appropriate Board certification or a 60 percent claims history, then increased payment would be available.
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FAQ ID:92706
SHARE URLIf the supervising physician does not self-attest to the physician specialty or subspecialty qualification under CMS 2370-F, can the physician supervise a mid-level provider? If the supervising physician self-attests to the 60 percent threshold, but not one of the defined specialty or subspecialty qualifications, can the physician supervise a mid-level?
The eligibility of services provided by mid-level/non-physician practitioners is dependent on 1) the eligibility of the physician and 2) whether or not the physician accepts professional responsibility for the services provided by the mid-level. As previously noted, physicians are eligible only if they first self-attest to a specified specialty designation and also to either being appropriately Board certified or having a 60 percent claims history.
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ÂFAQ ID:92711
SHARE URLIs it permissible for states with Medicare geographic adjustments that opt to develop rates based on the mean Medicare rate over all counties for each Evaluation & Management code under CMS 2370-F to use a weighted mean based on either the county population or the county Medicaid enrollment?
We believe this would be acceptable. However, the Centers for Medicare & Medicaid Services (CMS) would review the methodology as part of the SPA approval process.
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ÂFAQ ID:92716
SHARE URLIf a state were to proceed with implementation on January 1, 2013, and submit a state plan by March 31, 2013, would the Centers for Medicare & Medicaid Services (CMS) permit the state to claim the enhanced match for services that were reimbursed at the higher rate under CMS 2370-F prior to approval of the state plan?
No. As noted in the final rule, Federal Financial Participation (FFP) in increased rates will not be available until the State Plan Amendment (SPA) is approved.
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ÂFAQ ID:92721
SHARE URLWill Federally-Facilitated Exchange customer support personnel be familiar with state rules so that they can advise consumers adequately?
Yes. HHS will operate the Federally-Facilitated and State Partnership Exchange call center and website, and personnel will be trained on relevant state insurance laws and Medicaid and CHIP eligibility standards so that they can advise consumers. In a state operating in a State Partnership Exchange, a state will be responsible for the day-to-day management of the Exchange Navigators and the development and management of another separate in-person assistance program, and may elect to conduct additional outreach and educational activities. The Affordable Care Act directs Navigators to conduct public education to target Exchange-eligible populations, assist qualified consumers in a fair and impartial manner with the selection of qualified health plans and distribute information on tax credits and cost-sharing reductions, and refer consumers to any consumer assistance or ombudsman programs that may exist in the state. Navigators must provide this information in a manner that is culturally and linguistically appropriate and accessible by persons with disabilities.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94436
SHARE URLWhat restrictions will there be on a state regulator's authority to enforce state laws when consumers purchase coverage through a Federally-Facilitated Exchange? Will states retain their ability to protect consumers?
States have significant experience and the lead role in insurance regulation, oversight, and enforcement. We will seek to capitalize on existing state policies, capabilities, and infrastructure that can also assist in implementing some of the components of a Federally-Facilitated Exchange. We also encourage states interested in improving this alignment to apply to conduct plan management through a State Partnership Exchange.
A Federally-Facilitated Exchange's role and authority are limited to the certification and management of participating qualified health plans. Its role and authority do not extend beyond the Exchange or affect otherwise applicable state law governing which health insurance products may be sold in the individual and small group markets. Several qualified health plans certification standards rely on reviews that some state departments of insurance may not currently conduct. Therefore, HHS will evaluate each potential qualified health plan against applicable certification standards either by deferring to the outcome of a state's review (e.g., in the case of licensure) or by performing a review necessary to verify compliance with qualified health plan certification standards. Federally-Facilitated Exchanges will consider completed state work to support this evaluation to the extent possible.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94441
SHARE URLHow will the Federally-Facilitated Exchange be funded?
To fund the operation of the Federally-Facilitated Exchange, we proposed for comment in the draft Payment Notice that participating issuers pay a monthly user fee to support the operation of the Federally-Facilitated Exchange. For the 2014 benefit year, we proposed a monthly user fee rate that is aligned with rates charged by State-Based Exchanges. While we proposed that this rate be 3.5 percent of premium, it may be adjusted in the final Payment Notice to take into account State-Based Exchange rates. Exchange user fees will support activities such as the consumer outreach, information and assistance activities that health plans currently pay themselves. This policy does not affect the ability of a state to use grants described in section 1311 of the Affordable Care Act to develop functions that a state elects to operate under a State Partnership Exchange and to support state activities to build interfaces with a Federally-Facilitated Exchange.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94446
SHARE URLIf a state chooses to provide some services to a Federally-Facilitated Exchange, will the state be reimbursed for its costs?
Yes in certain circumstances. HHS expects that states supporting the development of a Federally-Facilitated Exchange may choose to seek section 1311(a) Exchange Establishment cooperative agreement funding for activities including, but not limited to:
- Developing data system interfaces with the Federally-Facilitated Exchange;
- Coordinating the transfer of plan information (e.g., licensure and solvency) from the state insurance department to the Federally-Facilitated Exchange; and
- Other activities necessary to support (and related to the establishment of) the effective operations of a Federally-Facilitated Exchange.
After section 1311(a) funds are no longer available, HHS anticipates continued funding, under a different funding vehicle, for state activities performed on behalf of the Federally-Facilitated Exchange. To the extent permissible under applicable law, HHS intends to make tools and other resources used by the Federally-Facilitated Exchange available to state partners in State Partnership Exchanges, as well as to State-Based Exchanges.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94451
SHARE URLHow are Exchanges going to increase insurance market competition based on quality and cost? Some markets may be starting off from a position of having few local issuers.
The introduction of Exchanges and the insurance market rules in 2014 will help promote competition based on quality and cost since consumers will have an unprecedented ability to compare similar products from different issuers and will be assured the right to purchase these products, regardless of their health condition. Further, consumers in many states will have new options such as the ability to purchase coverage from the Consumer Operated and Oriented Plans and Multi-State Plans created under the Affordable Care Act. Additionally, Exchanges can leverage market forces to drive further transformation in health care delivery.
We anticipate that the number of individuals who will be eligible for advance payments of premium tax credits and cost-sharing reductions - which are only available in connection with qualified health plan coverage purchased through an Exchange - will attract issuers to Exchanges where the certification process will encourage and reward high quality affordable insurance offerings. In addition, HHS is developing a Star Ratings system for qualified health plans purchased in an Exchange pursuant to section 1311(c)(3) of the Affordable Care Act.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94456
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