Frequently Asked Questions

States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.

FAQ ID:91091

Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.

FAQ ID:91096

Preventive services include immunizations, screenings for common chronic and infectious diseases and cancers, clinical and behavioral interventions to manage chronic disease and reduce associated risks, and counseling to support healthy living and self-management of chronic conditions, such as those associated with obesity. A list of preventive health care services recommended as Grade A or B by the U.S. Preventive Services Task Force can be found at: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.

Through Medicaid's children's benefit - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - children under age 21 enrolled in Medicaid are assured coverage for preventive and comprehensive health services. States cover adult preventive services within Medicaid through both mandatory and optional benefit categories. Some preventive services (such as those related to family planning) may be defined in a state's mandatory set of benefits while others may be included in the optional benefit category. As a result, Medicaid programs differ from state to state on the coverage of preventive services for adults.

Obesity-related services are those services that help prevent and manage unhealthy weight. Medicaid and CHIP programs can cover a range of services to prevent and reduce obesity including Body Mass Index (BMI) screening, education and counseling on nutrition and physical activity, prescription drugs that promote weight loss, and, as appropriate, bariatric surgery.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92666

Affordable Care Act Section 4004(i)(2) calls for "state public awareness campaigns to educate Medicaid enrollees regarding availability and coverage of preventive and obesity related services with the goal of reducing incidences of obesity." The statute tasks states with designing the public awareness campaign because states have a better understanding of what outreach efforts will best meet the needs of their state Medicaid and CHIP population. Activities that provide information to beneficiaries about the preventive and obesity-related services covered in the state's Medicaid and CHIP programs will satisfy the requirement. Federal funding would be available for such activities as administrative costs of the Medicaid and CHIP programs.

Some resources that states may want to consider as they move forward with their activities include:

• Healthy Weight, Healthy People, Healthy Communities page on the Health Resources and Services Administration's website
• Centers for Disease Control and Prevention's Nutrition, Physical Activity and Obesity 
• "F as in Fat: How Obesity Threatens America's Future 2012," issued by the Trust for America's Health and the Robert Wood Johnson Foundation

States can receive the 50 percent Medicaid administrative matching rate for public awareness campaign activities, and will receive their existing Federal Medical Assistance Percentage (FMAP) rate for preventive services.

The Affordable Care Act includes additional funding for states that cover Grade A and B recommended services of the US Preventive Services Task Force (USPSTF) and all Advisory Committee on Immunization Practices (ACIP) recommended adult vaccines and their administration without cost sharing. CMS has released separate guidance on that provision which can be found at https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SMD-13-002.pdf (PDF, 138.73 KB).

In addition, CMS can provide technical assistance to states with reporting and interventions that they have in place to improve performance on the prevention core measures.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92671

Yes, if a state has undertaken an initiative to provide information on Medicaid coverage of preventive services since the passage of the Affordable Care Act in March 2010 then they have met this requirement.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 86.67 KB)

FAQ ID:92676

If these practices and health systems maintain the types of documentation described in the previous answer, FAQ45736, with respect to managed care organizations, attestation by the group or system would be acceptable. As previously noted, a physician actually must be practicing as an internist, pediatrician or family physician in order to be eligible for higher payment. Board certification does not always equate to practice characteristics. Therefore, attestation on the basis of information on board certification alone would not suffice.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93866

No. The attestation and eligibility are physician-specific. If a physician provides services both in a fee-for-service and managed care environment, they need only complete the process of attestation once in order to receive higher payment for all eligible services they provide. CMS expects all information on self-attestation to be fully available to the state, regardless of which party collected this information.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93871

States have the flexibility to count eligible services provided by a physician in neighboring states in meeting the 60 percent threshold, but are not required to do so.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93876

These services would not be subject to the minimum payment standard set in the rule because there are no RVUs and there is no conversion factor associated with them. Therefore, a Medicare-like rate cannot be developed. The state may continue to reimburse them at the current Medicaid rate but enhanced federal financial participation (FFP) will not be available for those services.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93881

No. Verification of current board certification is sufficient.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 25.85 KB)

FAQ ID:93886