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, may states continue to use discounted reimbursement rates for out-of-state or out-of-network eligible primary care providers, which may be less than the Medicare rate, for calendar years (CYs) 2013 and 2014?
CMS acknowledges the customary practice of reimbursing out-of-state or out-of-network providers at a base rate minus a defined percentage. The applicable Medicare rate effectively becomes the ‘floor’ for payments to eligible providers for eligible services rendered in CYs 2013 and 2014. Health plans may pay above that rate but not below.
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FAQ ID:92131
SHARE URLUnder CMS 2370-F, CMS has indicated that the CMS-64 will be modified for states to report the expenditures that will receive the 100 percent federal medical assistance percentage (FMAP) for the increased expenditures for primary care services. Will the CMS-21 also be modified to report these expenditures for the CHIP Medicaid Expansion population?
No. The only expenditures that count against the CHIP allotment and must be reported on the CMS-21 are those related to the Medicaid rate in effect on July 1, 2009. The difference between those rates and the 2013 and 2014 Medicare rates eligible for 100 percent FMAP are Medicaid expenditures and are reported on the CMS 64.9.
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FAQ ID:92116
SHARE URLOur state uses multiple cost centers (routine and ancillary) in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple cost centers?
Yes, the templates allow the use of multiple cost centers. For example, if the state uses a cost methodology for ancillary services and a per-diem methodology for routine services, the state will complete one cost template and one per-diem template in order to account for these two cost centers. Every hospital would be featured in each of the two templates; however, to differentiate their provider information, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the cost template as 123456-A and in the per diem template as 123456-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number. If there are multiple cost centers under either the cost or per-diem methodology, the state would separate out the cost centers within their respective templates. Each cost center should be associated with only one appended letter and these should be described in the notes tab. When using multiple cost centers, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.
FAQ ID:92261
SHARE URLOur state uses multiple cost centers with varying cost-to-charge ratios in our calculation of the inpatient hospital Upper Payment Limit (UPL). Does the template accommodate this?
Yes, the template allows the use of multiple cost centers with multiple cost-to-charge ratios. The state would separately report the costs and payments associated with each of the cost centers in the cost template. To differentiate the cost centers, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, for example an -A, -B, or -C, that would be used as a unique identifier for each cost center.
FAQ ID:92266
SHARE URLOur state uses multiple methodologies for the three ownership categories in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple methodologies?
Yes, the templates allow the use of multiple methodologies. The state would complete the templates associated with the UPL methodologies used. For example, if the state uses a cost-based methodology for state owned hospitals and a payment-based methodology for private hospitals, then the state would complete the cost template for the state owned hospitals and the payment template for the private hospitals. When using multiple methodologies, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.
FAQ ID:92271
SHARE URLHow and when should the Medicaid hospital tax/provider assessment be included in the inpatient hospital template?
The cost of the tax should be reported in Variable 401 - MCD Provider Tax Cost. A state may separately report the Medicaid portion of the cost of a provider assessment/tax only when it is using a cost based methodology to calculate the UPL. A state may not include this cost when calculating a DRG or Payment based UPL demonstration.
FAQ ID:92366
SHARE URLHow should cost data reported for a partial year be treated either when one hospital acquires another hospital or a hospital ceases operation?
When a hospital acquires another hospital, the state should use all available data to determine the UPL and work with CMS to assure appropriate reporting. When a hospital ceases operation, the state should not annualize data if it does not cover a 12-month period.
FAQ ID:92391
SHARE URLHow is the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) different from other institutional UPLs?
Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.
FAQ ID:92416
SHARE URLIs the state required to report in the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) template the number of service days for Medicaid beneficiaries?
Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.
FAQ ID:92421
SHARE URLDo allergists qualify for higher Medicaid payment under the CMS 2370-F rule?
CMS recently received information from the American Board of Medical Specialties attesting that the American Board of Allergy and Immunology (ABAI) is an ABMS-recognized sub-discipline of the American Board of Pediatrics and the American Board of Internal Medicine.
Specifically, the ABAI is a conjoint board of the American Board of Pediatrics (ABP) and the American Board of Internal medicine (ABIM). All physicians certified by the Board of Allergy and Immunology must first be board certified by either ABP or ABAI. Medical specialists certified by the Allergy and Immunology Board remain subspecialists of Internal Medicine and Pediatrics. However, it is possible that some holders of a certificate from ABAI will not have a current certificate in Internal Medicine or Pediatrics because some diplomats of the ABP and ABIM who hold subspecialty certificates are not required to maintain their primary certificates. The ABMS was concerned that these diplomats might be excluded from eligibility for higher payment under a strict interpretation of the rule even though they do act as their patients' primary care provider in many cases and urged that CMS formally recognize that diplomats of ABAI are, in fact subspecialists in Internal Medicine and Pediatrics and eligible for higher payment up to the Medicare rate.
Based on this information, CMS agrees that allergists are eligible for higher payment under the rule.
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FAQ ID:91486
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