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
Under CMS 2370-F, there are several codes for which there are relative value units (RVUs), but a rate does not calculate for the non-facility setting. For example, 99217-99221 (observation codes) only have a facility fee. If the state is electing the option of paying the non-facility fee, should it use the facility fee or is there an alternative method for calculation?
When there are RVUs for just one site of service the state should use those RVUs. There is no alternate method for calculation.
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FAQ ID:93896
SHARE URLIn our state, the Medicaid agency instructs Rural Health Centers (RHCs) to bill the Medicaid agency for the administration of a Vaccines for Children Program (VFC) immunization by using the provider's individual provider number for each immunization administration and the RHC/Medicaid group number for payment to the RHC for other medical services. Under the CMS 2370-F rule, do RHC's not qualify for enhanced payments on E&M codes billed with the RHC Medicaid facility provider number, but the individual providers do qualify for enhanced payment on VFC administration? Given that my state also requires RHCs to bill for E&M hospital codes such as 99221 or 99223 by using the individual treating provider's number, shouldn't the individual providers be "qualifying" providers for the purpose of enhanced payments for these hospital codes?
Providers such as RHCs and Federally Qualified Health Centers (FQHCs) are reimbursed on the basis of an all-inclusive rate under their own Medicaid benefit categories. As specified in the final regulation, only services provided under the physician benefit and billed using a physician fee schedule are eligible for higher payment. In your examples, since the state reimburses the vaccine administration and the hospital codes on a fee-for-service basis and does not pay then all-inclusive rate, those services would be eligible for higher payment if the physician who provides them properly self attests to eligibility. However, services provided by the physician that are reimbursed through the all-inclusive rate would not be eligible.
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FAQ ID:93901
SHARE URLUnder CMS 2370-F, we interpret 42 CFR 447.205 to not require public notice of a state's implementation of section 1202 of the ACA because "the change is being made to conform to Medicare methods or levels of reimbursement". Does CMS interpret this regulation differently?
CMS agrees that 42 CFR 447.205(b)(1) excepts states from the public notice requirements when a change is being made to conform to Medicare reimbursement. However, states must still ensure that providers are properly notified of the requirements for self-attestation and higher payment through provider bulletins or other mechanisms.
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FAQ ID:93906
SHARE URLUnder CMS 2370-F, are the services of "physician extenders" (defined as physicians who provide services in support of eligible physicians) eligible for higher payment when an eligible primary care specialist bills for their services? Examples of "physician extenders" include neurologists, OB/GYNs, pathologists, anesthesiologists and surgeons who provide services to the patients of eligible physicians.
No. The only services that qualify are those provided directly by physicians (or by non-physician practitioners that they supervise) who self-attest to an eligible primary care designation and whose attestation is supported by evidence of board certification or claims history. Physicians who do not qualify on their own merits cannot receive higher payment by having an eligible physician bill on their behalf. As previously noted, physicians must accept professional responsibility/liability for the services provided by non-physician practitioners under their supervision.
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FAQ ID:93911
SHARE URLUnder 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
SHARE URLThe 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
SHARE URLAs 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
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.
Supplemental Links:
- 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
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