Frequently Asked Questions

Regardless of whether an EQRO contract is approved before or after May 6, 2016, the change in FFP for EQR-related activities was effective May 6, 2016 for expenditures incurred by the state on or after May 6, 2016. Per general CMS-64 claiming principles, a state incurs an expenditure that may be claimed on the CMS-64 on the date the state pays the EQRO for the completed performance of the contracted EQR-associated activity.

The change to the FFP match rate for expenditure reporting takes effect in the middle of a quarter, which means that states must ensure that claims for expenditures for EQR activities affected by the change in FFP which were paid before May 6th and claims for expenditures which were paid on or after May 6th are reported separately. For only the quarter ending June 30, 2016, the CMS-64 EQRO Line 17 will allow states to report state expenditures associated with PIHP EQRO activities paid prior to May 6, 2016 and claim the enhanced 75 percent match. State expenditures associated with PIHP EQRO activities paid on or after May 6th must be claimed at the 50 percent matching rate.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94651

CMS expects to first issue revised protocols for the current mandatory and optional EQR-related activities in the Fall of 2017. We expect to issue the protocol for the new mandatory EQR activity relating to the validation of network adequacy later in 2017 or early 2018. States will have up to one year from the publication of the protocol to implement the new mandatory EQR activity.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94656

For questions related to state expenditure reporting and claiming instructions for EQR activities, please contact your CMS regional office financial representative. For specific external quality review questions, including what activities qualify for enhanced match, please contact the Division of Quality and Health Outcomes at ManagedCareQualityTA@cms.hhs.gov.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94666

Yes. CMS acknowledges that states may have legitimate reasons to set capitation rates for a time period that differs from 12 months and will take unusual circumstances into account when reviewing compliance with the rating period duration requirements. CMS will approve a rating period other than of 12 months when a state transitions the contract term and rating period from a calendar year to a state fiscal year basis and setting capitation rates for a 6 month or 18 month period would facilitate that transition. There may be other reasonable justifications for such variations in the rating period that CMS would be open to considering. The rationale for a rating period that differs from 12 months as defined in the regulation in section 438.2 should be specified in the rate certification required in section 438.7 for such consideration.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93456

The implementation date for non-risk PIHPs and PAHPs, PCCMs, and PCCM entities for provisions tied to a rating period is the earliest date that a risk-based MCO, PIHP, or PAHP would need to comply. For example, the provisions in subpart F relating to appeals and grievances have an implementation date for risk-based contracts of the rating period for contracts starting on or after July 1, 2017. Non-risk PIHPs and PAHPs would need to implement those provisions by July 1, 2017.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93461

The regulation at section 438.3(m) has a general reference to "generally accepted accounting principles" and "generally accepted auditing principles." This means that states have the flexibility to specify the applicable generally accepted accounting and auditing principles for the audited financial reports in the managed care plan contracts. The federal regulation does not endorse a particular standard.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93466

Under the "Records" tab, select "Medicaid State Plan". Next, search for a state using the search feature in the left panel. Select the blue link for your State Plan. On the next screen you will be able to see past, current and future Health Homes Programs.

FAQ ID:92856

FAQ ID:92861

The State has the option to allow CMS to view the information in a submission package prior to submission informally by using the "Allow CMS to View" functionality. The CMS Point of Contact, Submission Review Team, and Subject Matter Expert have the ability to view these submission packages once the state has initiated the function. Please Note: This option will permit the CMS review team to see the screens in this submission package as they appear currently. It does not cause the package to be submitted as Draft or Official, and does not start a CMS review clock. Validation of the screens is not required. States must notify their CMS contact that viewing is available; MACPro does not notify CMS staff. States can deselect this option at any time

To access the submission package, go to the "Records" tab and then select "Submission Packages". Next select the link to the submission package and then in the left panel, select "Reviewable Units". You may then select the blue links to each Reviewable Unit to view the data entered by the state.

FAQ ID:92866

FAQ ID:92871