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Frequently Asked Questions

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.

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Is there a difference between the definition of Indian/Native American for Medicaid and the Exchange. Can you clarify what the difference is?

For purposes of eligibility for coverage through the Marketplace, the Affordable Care Act defines Indians as individuals who are members of a federally recognized Indian Tribe. The definition of Indian currently in use for Medicaid beneficiaries follows a broader definition that includes descendants of Indians and all American Indians and Alaska Natives. As a result, American Indians and Alaska Natives who are not members of an Indian tribe would not be eligible for exemptions available through an Exchange, including from individual responsibility payments, qualification for special monthly enrollment periods and cost-sharing reductions.

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FAQ ID:92576

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What are some examples of income that is not considered taxable, and therefore excluded from MAGI?

Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Veterans' disability, Workers' Compensation, child support, federal tax credits, and cash assistance are common types of income that are not taxable. Please see Question 5 below for additional details on veterans' benefits.

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FAQ ID:92581

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Will Veterans Administration (VA) benefits be counted as taxable income effective January 1, 2014?

The IRS has provided guidance on how VA benefits should be considered when calculating income. As noted in IRS Publication 17, states should not count any veterans benefits paid under any law, regulation or administrative practice administered by the Department of Veterans Affairs in their income calculations. CMS agrees that VA benefits are not part of the Modified Adjusted Gross Income (MAGI) calculation.

Following are some examples of payments issued to veterans' or their families that are not taxable:

  • Education, training and subsistence allowances
  • Disability compensation and pensions payments for disabilities paid either to veterans or their families
  • Grants for homes designed for wheelchair living
  • Grants for motor vehicles for veterans who lost their sight or the use of their limbs
  • Veterans' insurance proceeds and dividend paid either to veterans or their beneficiaries, including the proceeds of a veteran's endowment policy paid before death
  • Interest on insurance dividends left on deposit with the VA
  • Benefits under a dependent care assistance program
  • The death gratuity paid to a survivor of a member of the Armed Forces who died after September 10, 2001
  • Payments made under the compensated work therapy program
  • Any bonus payment by a state or political subdivision because of service in a combat zone

Additional information on how the IRS views veteran's income can be found at http://www.irs.gov/pub/irs-pdf/p17.pdf.

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FAQ ID:92586

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How should states handle eligibility renewals between January 1, 2014 and March 31, 2014 in order to comply with the ACA provisions that prohibit states from terminating an individual's existing Medicaid eligibility prior to April 1, 2014.

According to section 1902(e)(14)(D)(v) of the Act, implemented at 42 CFR 435.603(a)(3), a person enrolled in Medicaid on or before December 31, 2013, shall not be found ineligible solely because of the application of MAGI and new household composition rules before March 31, 2014, or the individual's next regular renewal date, whichever is later.

States have two options regarding implementation. They can apply both pre-MAGI rules and MAGI rules to anyone whose renewal date falls between January 1 and March 31, 2014 as described below. Alternately, states may request the waiver authority to delay renewals outlined in our May 17, 2013 guidance titled, "Facilitating Medicaid and CHIP Enrollment and Renewal in 2014" (available at http://medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO-13-003.pdf).

The steps described below will ensure that Medicaid enrollees who come up for renewal between January and March 2014 are addressed appropriately. For example, for an individual who comes up for renewal on February 1, 2014, states need to:

  1. Conduct an eligibility redetermination by applying MAGI-based methods (at the converted income standard). If eligible, renew coverage for a 12-month period ending in February 2015.
  2. If the individual is found to be ineligible under step 1, determine whether s/he remains eligible based on 2013 (current) methods and income standard. If so, a finding of eligibility until April 1, 2014 is necessary under the 2013 methods. Go to step 4.
  3. If the individual is not eligible per either step 1 or 2, consider whether the individual might be eligible on other bases of eligibility, and pursue any possibilities. If no other pathways apply, provide the individual with notice of termination and appeal rights and transfer their account to the Exchange (or CHIP) for eligibility determination and enrollment in a QHP (or CHIP).
  4. On April 1, 2014, for those who remain eligible per step 2 (using 2013 methods and income standards), consider whether the individual qualifies on other bases of eligibility. If the individual does, renew eligibility until April 1, 2015. If not, provide notice and appeal rights for termination effective April 1, 2014.

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FAQ ID:92596

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Under CMS 2370-F, may practice managers or billing staff of large group practices and health systems attest on behalf of their physicians on the basis of information on board certification in the records of the practice or health system?

If these practices and health systems maintain the types of documentation described in the previous answer, FAQ45736, with respect to managed care organizations, attestation by the group or system would be acceptable. As previously noted, a physician actually must be practicing as an internist, pediatrician or family physician in order to be eligible for higher payment. Board certification does not always equate to practice characteristics. Therefore, attestation on the basis of information on board certification alone would not suffice.

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FAQ ID:93866

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Under CMS 2370-F, if a physician renders services in both the managed care and fee for service environments, must he or she self-attest to eligibility twice?

No. The attestation and eligibility are physician-specific. If a physician provides services both in a fee-for-service and managed care environment, they need only complete the process of attestation once in order to receive higher payment for all eligible services they provide. CMS expects all information on self-attestation to be fully available to the state, regardless of which party collected this information.

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FAQ ID:93871

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Under CMS 2370, may physicians who practice in two (or more) states meet the 60 percent threshold based on all services provided in all states, or must they qualify on the basis of the services they provide in each state?

States have the flexibility to count eligible services provided by a physician in neighboring states in meeting the 60 percent threshold, but are not required to do so.

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FAQ ID:93876

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There are at least two current procedural terminology (CPT) codes (99429 and 99499) for which there are no relative value units (RVU) and the state manually prices the services for purposes of Medicaid payment. Will CMS develop a Medicare-like rate for these codes under the CMS 2370-F rule?

These services would not be subject to the minimum payment standard set in the rule because there are no RVUs and there is no conversion factor associated with them. Therefore, a Medicare-like rate cannot be developed. The state may continue to reimburse them at the current Medicaid rate but enhanced federal financial participation (FFP) will not be available for those services.

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FAQ ID:93881

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Under CMS 2370-F, if a physician self-attests to being a primary care provider and supports that attestation with evidence of appropriate board certification, must we review that physician's practice to verify that they actually practice in that manner?

No. Verification of current board certification is sufficient.

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FAQ ID:93886

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Under CMS 2370-F, if a physician is board certified in a non-eligible specialty (for example dermatology) but practices within the community as for, example, a family practitioner and attests to meeting the 60 percent claims threshold, are we expected to audit his or her practice and, if so, how? May we be specific about our audit requirements in the state plan?

Since the only evidence of eligibility is the self-attestation and claims history, the state would need to take steps to verify the practice characteristics of the physician. This could be done by determining that the physician represents himself in the community as a family practitioner, as evidenced by medical directory listings, billings to other insurers, advertisements, etc.

While we have no objection to the addition of this information to the state plan amendment (SPA), we believe it is more important that the state make providers aware of the audit procedures and requirements as part of the enrollment process.

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FAQ ID:93891

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