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
If a manufacturer has a negative monthly AMP, should they use the most recent valid monthly AMP in the quarterly calculation?
CMS has previously provided guidance regarding the reporting of zero or negative AMP in Manufacturer Release #80 (January 5, 2010) in which we specify that if a calculated monthly AMP is zero or negative, we recommend that manufacturers report the most recent prior month's positive AMP. However, the actual calculated monthly AMP should be used to calculate the quarterly AMP. If the quarterly AMP is zero or negative, we recommend that manufacturers report the most recent positive AMP value. Please see Manufacturer Release #80: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Benefits/Prescription-Drugs/Downloads/Rx-Releases/MFR-Releases/mfr-rel-080.pdf. (PDF, 127.6 KB)
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94851
SHARE URLIf a manufacturer is currently not selling to entities or providers located in Puerto Rico and the U.S. Territories, will they be required to sell covered outpatient drugs to the U.S. Territories going forward (April 2017)?
The final rule does not require that a drug manufacturer sell its drugs to certain purchasers.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94856
SHARE URLFor smoothing of lagged price concessions and inclusion of sales from the U.S. Territories, should a manufacturer include the sales from the U.S. Territories in the 12 months of data for smoothing as of April 1, 2017 (going back to May 2016), or should they only include it in the smoothing only as of April 1, 2017 and prospectively?
Given the one year delay in the effective date of the definitions of states and United States, manufacturers should begin using sales data in their smoothing process beginning with sales that occur as of April 1, 2017.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94861
SHARE URLCan states rely on the information contained in the enhanced flat files?
We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.
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FAQ ID:91906
SHARE URLWhat action may the state take if the state believes there is another basis for excluding an individual from flat file-based enrollment based on state analysis or external information?
If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.
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FAQ ID:91921
SHARE URLWhat if a state later determines that a person enrolled based on information in the flat file is not eligible for Medicaid or CHIP?
In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.
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FAQ ID:91926
SHARE URLWe understand that if we use the expanded flat file for enrollment, applicants are eligible to receive Medicaid for 90 days for assessment states and that we will run them through a MAGI-based determination in the future. If we enroll someone based on the flat file, and then become aware of additional information regarding the individual's eligibility before we receive the full account transfer, do we need to act on that information?
Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.
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FAQ ID:91931
SHARE URLIf an application contains a household which is a mixed case with MAGI and non-MAGI individuals, how should the state process enrollment in this situation?
Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid under the MAGI standard, the state can process enrollment for MAGI individuals under the waiver authority. Since the FFM is providing non-MAGI applicant referrals on the expanded flat file, the state would act upon the non-MAGI referrals in the same manner as it would through the account transfer service.
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FAQ ID:91936
SHARE URLWhat are the security requirements for receiving and acting upon the expanded flat file? Can we follow processes consistent with paper applications (logging starts once the information is entered into the eligibility system)?
Yes, all the regulations and security constraints that apply to paper applications are necessary with the expanded flat file. The state would need to maintain the same level of security for the expanded flat file as they would in regard to paper applications.
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FAQ ID:91941
SHARE URLWhat if an account contains an out of state address?
Applicants can apply for whatever state they choose. Sometimes someone will want to file an application for a state they don't currently live in. For example, if they are temporarily residing outside the state or have a family member or tax dependent that needs coverage who lives there. When an applicant applies on the Federally Facilitated Marketplace (FFM), they provide their home address and that information is used to validate the eligibility criteria of state residency during the eligibility determination process. If an applicant does not indicate they have a home address in the state they are applying to, and they do not indicate they are temporarily absent from the state, they will be denied Medicaid, CHIP and APTC for that state in accordance with state and federal rules. However, an applicant can always request a full determination, and in doing so, the account is transferred to the state indicated. In order to respond, the state will need to verify residency, and approve or deny Medicaid as applicable.
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FAQ ID:91946
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