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
Are individuals who were in foster care and enrolled in Medicaid when they turned age 18 or aged out of foster care in a different state eligible under this group?
We do not believe the statue requires states to cover, under this group, individuals who were in foster care and enrolled in Medicaid when they turned age 18 or aged out of foster care in a different state. However, we believe the statute provides states the option to do so. As noted above, pending publication of a final regulation at section 435.150, states may exercise the option proposed when they complete SPA page S33 for this group.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)
FAQ ID:92166
SHARE URLAt state option, are states allowed to claim title XIX funding instead of title XXI for services provided under a Medicaid expansion program?
Yes. Section 115 of CHIPRA gives states the option to claim expenditures for Medicaid expansion program populations under section 1905(u)(2)(B) of the Act, either at the enhanced FMAP rate using title XXI funds or at the regular FMAP rate using title XIX funds. States that elect to claim expenditures under title XXI will receive the enhanced FMAP rate. However, states that elect to claim expenditures under title XIX will receive the regular Medicaid FMAP rate. Claims submitted at the enhanced FMAP rate will be paid from the state's CHIP allotment.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)
FAQ ID:92171
SHARE URLProviders are permitted to charge a copay for a member's office visit. This visit may include a variety of services including preventive and non-preventive services. The State Medical Director (SMD) letter indicates the enhanced federal medical assistance percentage (FMAP) is available if cost-sharing is eliminated for preventive services. We believe this to mean that the doctor cannot collect a copay for any visit in which preventive services are provided, regardless of whether the majority of services provided during the visit are non-preventive services. We would like CMS verification.
If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.
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FAQ ID:92121
SHARE URLAre there any circumstances that would allow a state to apply the same Upper Payment Limit (UPL) demonstration to multiple years?
When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.
FAQ ID:92221
SHARE URLWhat information does CMS expect to be included in the Notes tab?
The Notes tab should include any and all information to fully support the state's UPL demonstration. CMS expects states to provide clarifying information in the Notes tab. For example, this information would provide details for the adjustments to Medicare as input in variables 212.1 and 212.2, various supplemental payments in variables 313.1, 313.2, and 313.3, and adjustments to Medicaid in variables 314.1 and 314.2. In addition to reporting through the notes tab, the state also has the option of using the guidance document or narrative to fully support its UPL demonstration.
FAQ ID:92376
SHARE URLThe state is under the impression that they only need to update the 3.1-A coverage pages for preventive services to claim the 1% federal medical assistance percentage (FMAP) increase under section 4106 of the Affordable Care Act. Does the state need to update their reimbursement pages as well to provide the required assurances?Can you please advise if CMS will require public notice in addition to the state plan amendment (SPA) for the 1% FMAP increase to take effect?
In order to receive the one percentage point FMAP increase, the state is required to submit a SPA with updated coverage pages. When a SPA is submitted with updated coverage pages, we will perform a review of the corresponding payment page(s). A state does not need to submit a SPA with revised payment pages, and conduct public notice, unless it wishes either to begin coverage and payment for these services or to change the existing payment rates (in other words, if the state already pays for the preventive services in some contexts, a payment SPA may not be needed if the state does not want to change the existing payment rate or methodology).
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FAQ ID:91516
SHARE URLUnder what portion of the state plan should the state add the Affordable Care Act section 4106 information?
The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.
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FAQ ID:91521
SHARE URLDoes a state that has both a fee-for-service (FFS) and a managed care delivery system, get the 1% federal medical assistance percentage (FMAP) increase when just the FFS benefit is amended or would the state have to concurrently amend its managed care authority document (state plan amendment (SPA), waiver or 1115 demonstration project) to get the 1% FMAP increase under section 4106 of the Affordable Care Act?
A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit. To claim that enhanced FMAP for managed care payments, CMS must review the methodology that the state intends to use to estimate the value of the preventive services benefit in its capitation rates.
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FAQ ID:91526
SHARE URLAccording to the United States Preventive Services Task Force (USPSTF) methodology "The Task Force also aims to update topics every five years, in order to keep recommendations in the Task Force library current according to criteria established by the National Guideline Clearinghouse. Under section 4016 of the Affordable Care Act, does the requirement of covering and claiming increased federal financial participation (FFP) for USPSTF A and B recommendations apply only to recommendations that are new, updated, or reaffirmed within the past five years?
Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.
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FAQ ID:91531
SHARE URLAre fluoride treatments (also known as fluoride varnishes) eligible for the one percentage point increase in federal medical assistance percentage (FMAP) under section 4106 of the Affordable Care Act?
No, fluoride varnish is not eligible for the one percentage point FMAP increase. In the future, if the United States Preventive Services Task Force (USPSTF) adds fluoride varnish to the A or B recommended preventive services, states will be required to cover the fluoride varnish with no cost-sharing. Per State Medical Director (SMD) letter #13-002, states should provide an assurance in the state plan indicating they have a method to ensure that, as changes are made to the USPSTF and the Advisory Committee on Immunization Practices (ACIP) recommendations, they will update their coverage and billing codes to comply with those revisions. As long as this assurance is in the state plan, states are not required to submit a state plan amendment each time the USPSTF or ACIP makes changes to their recommendations.
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FAQ ID:91536
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