Frequently Asked Questions

If a state has elected to provide PE for individuals with breast or cervical cancer under section 435.1103(c)(2), it can limit qualified entities under that section to providers who conduct screenings for breast and cervical cancer under the state's CDC BCCEDP, and if it has done so, the state may limit hospitals that may determine PE for individuals with breast or cervical cancer on that basis to hospitals that conduct screenings under the state's BCCEDP. In states that do not opt to provide PE for individuals with breast or cervical cancer under section 435.1103(c), states similarly may limit hospitals' ability to determine PE for individuals with breast or cervical cancer under section 435.1110 to those that conduct screenings under the state' BCCEDP.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91651

When hospitals determine PE, they are subject to the same general rules set out for other qualified entities that may determine PE, including that they cannot "delegate the authority to determine presumptive eligibility to another entity." (See 42 CFR 435.1102(b)(2)(vi). However, they may implement PE with the support of third party contractors. For example, hospitals can rely on third party contractors to help staff their in-hospital PE operations, by staffing welcome desks, meeting with consumers, and helping them fill out PE applications as long as the hospital takes responsibility for the PE determinations that result. In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application.

Hospitals that conduct off-site, targeted outreach may also employ third party contractors to reach out to individuals who may be Medicaid eligible and assist them with a presumptive application and the single streamlined application at the individual's request. Hospitals must oversee such off-site outreach to ensure hospital accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. States should not unduly limit a hospital's ability to rely on third-party contractors as long as the hospital is not delegating its authority to determine presumptive eligibility to a third party and is meeting appropriate state-established performance standards.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91656

Keeping track of all eligible providers is important to ensure ongoing training and that the providers have regular updates in policy as well as to review performance, implement performance standards and develop quality assurance measures. Some states maintain a centralized list of all providers who have completed the process for learning the state's policies and procedures; the state may wish, for example, to periodically review the list by calling all identified providers or settings and asking whether or not listed individuals are currently conducting PE determinations. It is important for states to ensure, over time, that hospital PE is functioning throughout the state.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91671

States have used a number of strategies to engage hospitals, such as reaching out to the state hospital association or local hospital groups, sending hospitals a letter of interest to get feedback on their plans to participate in the program, and inviting hospital representatives to teleconferences and webinars about the policy. CMS has also reached out to various hospital associations to advise them of this new provision and the federal guidance supporting it.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91681

The Affordable Care Act provides significant federal support to ensure the availability of coverage to low-income adults. Enrollment caps limit enrollment in coverage on a first come, first serve basis. Periods of ineligibility delay or deny coverage for otherwise eligible individuals. These policies do not further the objectives of the Medicaid program, which is the statutory requirement for allowing section 1115 demonstrations. As such, we do not anticipate that we would authorize enrollment caps or similar policies through section 1115 demonstrations for the new adult group or similar populations.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93751

Demonstrations focused on changes to how health care services are delivered, such as the use of managed care, will not generally affect the state's matching rate. Please refer to our February 2013 FAQs (PDF, 135.35 KB), which provide further clarification on the two increased federal match rates: the newly eligible rate and the expansion state rate as well as the final FMAP rule published on April 2, 2013. Additionally, CMS issued two State Medicaid Director letters, on July 10, 2012, that provide guidance on how states can adopt integrated care models without the need for a section 1115 demonstration.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93756

Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94276

As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94361

The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94376

States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.

FAQ ID:92686