Frequently Asked Questions

States are free to establish higher rates for particular items of DME if they determine that higher rates are needed under the Medicaid state plans. If, however, the aggregate expenditures would exceed the Medicare rates in the aggregate, federal financial participation (FFP) would be limited. States that determine that payments above Medicare aggregate totals are necessary may use state-funds to obtain particular items of DME. The statute specifically describes an aggregate limit on state expenditures only for purposes of paying FFP. Therefore, a state may pay more than the Medicare rate for a particular item of DME, and as long as the aggregate amount for all DME is not exceeded, no FFP is at risk. Even if the aggregate amount is exceeded, there is only a limit on FFP, and there is no limit on the use of state funds used on DME items.

FAQ ID:93496

The Centers for Medicare & Medicaid Services cannot delay implementation of the statute. Congress took specific action to move the effective date up to January 1, 2018, and we are unable to amend the effective date.

FAQ ID:93501

The limit on FFP is the total aggregate amount for all relevant DME subject to the limit described in Section 1903(i)(27) of the Act.

FAQ ID:93506

The guidance document references 42 CFR 414.202. The regulation defines “durable medical equipment” as equipment, furnished by a supplier or a home health agency that meets the following conditions:

• Can withstand repeated use
• Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least three years
• Is primarily and customarily used to serve a medical purpose
• Generally is not useful to an individual in the absence of an illness or injury
• Is appropriate for use in the home

FAQ ID:93511

Medicare payment amounts for durable medical equipment (DME) are available through CMS.gov (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html) and through DMECompetitiveBid.com, which is the Medicare website for the competitive bidding program. States may access the appropriate information through these resources, or upon request through MedicaidDME@cms.hhs.gov.

FAQ ID:93516

For technical assistance with the implementation efforts and assistance with determining if current state practices are below the FFP limit, please contact the Medicaid DME mailbox: MedicaidDME@cms.hhs.gov.

FAQ ID:93476

States may review Medicare’s CBAs through the following website for the most up-to-date information: www.dmecompetitivebid.com. In the alternative, the Center for Medicaid and CHIP Services (CMCS) has a list of states and CBAs by state that is available upon request. We will monitor the lists and update them with any necessary Medicare changes. As of January 1, 2018, the following states and territories do not have CBAs: Alaska, Maine, Vermont, North Dakota, South Dakota, Montana, Wyoming, and all of the US territories.

FAQ ID:93481

No, CMS does not require any particular starting point within the fiscal year for the UPL demonstrations. This allows states the flexibility to develop UPL demonstrations that are tied to the provider payment periods described in the state plan payment methodologies for each service. For instance, if a state submits a state plan amendment to update provider payments as of October 1 of each year, the state would document that the SPA changes comply with the UPL for the period 10/1 - 9/30 of that payment year. The UPL must represent the entire payment year. Since UPL demonstrations usually rely on historic data that is projected into a payment year, this is consistent with past practices.

FAQ ID:92226

The state should report the expected amount of supplemental payments to be made during the period covered by the UPL demonstration. Supplemental payments should be entered into variables 303.1, 303.2, and 303.3 for the Inpatient Hospital and Outpatient Hospital templates and 313.1, 313.2, and 313.3 for the Nursing Facility templates. The state should provide detail in the notes tab on the types of supplemental payments and the related dollar amount of each payment.

FAQ ID:92291

CMS plans to provide technical assistance on transition plans to States through the State Operations and Technical Assistance Team (SOTA) calls and through other calls with the State. We will also be providing additional guidance about the information that should be included in the transition plans. We will consider the transition plans that need to be submitted by the due date as living documents that are open to revision, and will continue to work with States to ensure a seamless transition in 2014 for beneficiaries and States.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 55.99 KB)

FAQ ID:93021