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
Will the Federally-Facilitated Marketplace apply Medicaid policies and verification procedures differently under the "assessment" and "determination" models?
In an assessment model, the Federally-Facilitated Marketplace will not make a final Medicaid determination. Instead, the Federally-Facilitated Marketplace will transmit the account to the Medicaid or CHIP agency when they have evaluated the individual and identified him or her as Medicaid or CHIP eligible, and the Medicaid or CHIP agency will make the formal determination. In a determination model, the Medicaid or CHIP agency delegate the authority to make determinations to the Federally-Facilitated Marketplace. In both an assessment and determination model, as described in more detail in 42 CFR section 435.1200, the Federally-Facilitated Marketplace will utilize the same set of eligibility criteria, including selected state-specific options and standard verification procedures. If the state agency chooses the determination model, it must accept the Federally-Facilitated Marketplace determination as final. If the state chooses the assessment model, it must accept findings made by the Federally-Facilitated Marketplace relating to a criterion of eligibility, as long as the Federally-Facilitated Marketplace applies the same policies and verification procedures as those the state agency employs. In a state with a separate CHIP agency, the state Medicaid and CHIP agencies can make different choices allowing the Federally-Facilitated Marketplace to make an assessment or determination. States must choose either the assessment or determination model for all applications; they may not choose between models on a case-by-case basis. States will need to indicate their assessment or determination decision to CMS in a State Plan Amendment, as well as in the Memorandum of Agreement it signs with the Federally-Facilitated Marketplace.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93731
SHARE URLIn an assessment model, an applicant may be assessed eligible by the Federally-Facilitated Marketplace and later receive a determination as ineligible by the state Medicaid/CHIP agency. Does the state Medicaid agency need to communicate the eligibility finding to the Federally-Facilitated Marketplace?
Yes. In an assessment model, where an applicant is assessed eligible by the Federally-Facilitated Marketplace and later found to be ineligible by the state Medicaid agency, the state must transfer the account to the Federally-Facilitated Marketplace. Once received, the state Medicaid determination will be accepted and the account will be assessed by the Federally-Facilitated Marketplace for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits/Cost Sharing Reductions.
For the determination model, as discussed in section 435.1200(c), as governed by the agreement signed between the Medicaid agency and the Federally-Facilitated Marketplace, the Federally-Facilitated Marketplace determines eligibility for individuals applying to the Federally-Facilitated Marketplace for Medicaid/CHIP based on MAGI, and the state Medicaid or CHIP agency agrees to accept eligibility findings made by the Federally-Facilitated Marketplace.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93736
SHARE URLIn an assessment model, if an applicant applied via the Federally-Facilitated Marketplace and is found eligible for Medicaid or CHIP, how will the Federally-Facilitated Marketplace coordinate with the state Medicaid or CHIP agency regarding eligibility, enrollment, redeterminations, or renewals for Medicaid/CHIP?
For individuals assessed eligible for Medicaid/CHIP by the Federally-Facilitated Marketplace, their account will be transferred to the state Medicaid/CHIP agency for a final determination. Once enrolled in Medicaid/CHIP, regardless of where the initial application was submitted, all updates, redeterminations and renewals are handled by the enrolling entity (e.g., the state Medicaid/CHIP agency). No further coordination would be needed with the Federally-Facilitated Marketplace except when an individual is found ineligible for Medicaid or CHIP during the redetermination process. In this case, the state agency would transfer the individual's account to the Federally-Facilitated Marketplace to be assessed for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits /Cost Sharing Reductions. The Federally-Facilitated Marketplace will not handle redeterminations or renewals for Medicaid/CHIP and will refer individuals to the appropriate site in the state as appropriate.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93741
SHARE URLWill the Federally-Facilitated Marketplace integrate its enrollment file with the state's client registry so that data for households participating in both state programs and the Marketplace can be synchronized? Will the Federally-Facilitated Marketplace routinely check the Medicaid/CHIP enrollment files to determine any overlap between the Federally-Facilitated Marketplace and Medicaid/CHIP enrollment logs?
No. There will not be integration of the Federally-Facilitated Marketplace and states' client registries. Instead, the Federally-Facilitated Marketplace will both verify current Medicaid/CHIP enrollment as part of the Federally-Facilitated Marketplace "applicant" application, and will also conduct quarterly checks of the Medicaid/CHIP enrollment files to determine any overlap with Federally-Facilitated Marketplace enrollment logs.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93746
SHARE URLAre Indian Health Services (IHS) excluded from the increased provider payments under CMS 2370-F? Is there any change in FMAP under CMS 2370-F for primary care services delivered through IHS?
IHS and tribal facilities are often not separately paid for physician services, but instead receive an all-inclusive rate for inpatient or outpatient service encounters. To the extent that a particular claim is made for primary care services furnished by an eligible physician, there is no exclusion from the requirement for provider payment at least equal to the Medicare Part B fee schedule rate. States would continue to receive Federal Medical Assistance Percentage (FMAP) at the 100 percent rate for services received through IHS and tribal facilities and reimbursed through the all-inclusive rate. For other physician services, including Medicaid payments for contract health services, states would receive the regular FMAP for the base payment, and 100 percent for the difference between the state plan rate in effect on July 1, 2009 and the applicable 2013 and 2014 Medicare rates.
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FAQ ID:93956
SHARE URLThe final rule under CMS 2370-F clarifies that the 60 percent threshold for eligibility is based on services billed. Are billed services to be defined based on the number of units submitted or dollars?
The 60 percent threshold is based on the number of billed services as identified by individual billing codes for the primary specialty being asserted. That is, the numerator equals total billed codes for Evaluation & Management (E&M) services for the primary specialty, plus vaccine administration services, and the denominator equals the total number of billed codes. Please note that a state may choose to use paid billing codes/services in place of billed codes.
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FAQ ID:93966
SHARE URLIf a physician does not provide an attestation by a date established by the State, can the State apply the increased payment under CMS 2370-F prospectively only (that is, to dates of services on and after the date of attestation)? If not, are we correct that 42 CFR 447.45(d)(1) applies such that the claim for additional reimbursement is not payable if the attestation is not received within 12 months of the date of service?
States can establish reasonable timeframes regarding the submission of attestations by physicians. We are aware that many states are experiencing delays in implementing the provisions of the regulation and we have also been made aware that there is considerable confusion on the part of providers regarding enrollment. We expect that states will provide physicians with ample notice of the procedures for enrollment that physicians will be given several months to comply with the requirements. If the state sets a reasonable timeframe, such as three months, and physicians do not enroll within that time, we believe that the state could make payment prospectively from the date of the physician's application as long as this policy is made clear to providers.
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FAQ ID:93981
SHARE URLDoes a physician have to self-attest under CMS 2370-F in 2014 as well as 2013? The rule does not indicate that the physician has to self-attest a second time and we don't want to do that, but some who qualified in 2013 (based on 2012 claims history) may not qualify in 2014 (based on 2013 claims history).
You are correct that the rule does not require the physician to submit a new self-attestation in 2014 although states could impose such a requirement. States can rely on the initial self-attestation for purposes of 2014 payments since we would not expect provider practices to vary significantly from year to year.
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FAQ ID:93991
SHARE URLWhat form must a physician use to self-attest and qualify for higher payment under CMS 2370-F under this provision?
Attestation forms are developed by the State Medicaid agencies. Physicians should contact their state Medicaid agency for information on the process for becoming eligible for higher payment in their state.
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FAQ ID:93996
SHARE URLWhile sports medicine is a subspecialty of internal medicine, it is also a subspecialty of non-primary care specialties? We would only qualify a physician for the board certification for the sports medicine subspecialty under CMS 2370-F when it is a subspecialty of internal medicine. Is this correct?
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