Frequently Asked Questions

The measure excludes plan members who are not ambulatory from the measure rate, but it is not necessary to report the number of members excluded with the measure’s performance rate.

FAQ ID:89006

No, a specific screening tool is not required for this measure. However, potential screening tools may include the Morse Fall Scale and timed Get-Up-And-Go test.

FAQ ID:89011

A falls screening is an evaluation of whether a Managed Long Term Services and Supports plan member has experienced a history of falls and/or problems with balance or gait. A falls risk assessment includes a balance/gait assessment and one other assessment component and should only be performed for members with a documented history of falls (at least two falls or one fall with injury in the past year).

FAQ ID:89016

Regulation at 42 CFR 447.000(c)(1) and (2) specifies Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, or their successor codes.

FAQ ID:92126

States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.

FAQ ID:92251

Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.

FAQ ID:92416

Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.

FAQ ID:92421

The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92106

Implementing regulations at 42 CFR 438.804 require states to submit to CMS a methodology for calculating the July 1, 2009, baseline rate for eligible primary care services and a methodology for calculating the rate differential eligible for 100 percent of Federal Financial Participation (FFP) by March 31, 2013. Further, 42 CFR 438.6 (c)(5)(vi) establishes Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PHIP) or Prepaid Ambulatory Health Plan (PAHP) contract requirements to comply with this provision. It is CMS's expectation that as soon as practicable after the State submits the required methodologies in 42 CFR 438.804 and receives CMS approval, the State will:

1. Submit revised actuarial certification documents reflecting the Medicare rate for eligible primary care services in their MCO, PIHP or PAHP capitation rates; and
2. Submit amendment(s) to this contract to ensure compliance with 42 CFR 438.6 (c)(5)(vi).

After CMS approval of the revised contract and rates, the MCO, PIHP or PAHP must direct the full amount of the enhanced payment to the eligible provider to reflect the enhanced payment effective January 1, 2013. Federal financial participation (FFP) is available at a rate of 100 percent for the portion of capitation rates attributable to these enhanced payments; however, receipt of the enhanced FFP is contingent upon the state's successful completion of this process.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91266

Yes. A state may elect to delegate the self-attestation process to its contracting health plans under the following circumstances:

1. Each managed care plan has signed documentation on file (provider contract or credentialing application) from the eligible provider attesting to the fact that he or she has a covered specialty or subspecialty designation. This addresses step one of the two-step self-attestation process specified in the rule.
2. The managed care plan has verification of the provider’s appropriate board certification (as part of the credentialing and re-credentialing process). This addresses one option of the second step in the self-attestation process.
3. Should board certification in the eligible specialty not be able to be verified by the managed care plan, the eligible provider must provide a specific attestation to the managed care plan that 60 percent of their Medicaid claims for the prior year were for the Healthcare Common Procedure Coding System (HCPCS) codes specified in the regulation. This addresses a second option for the second step in the self-attestation process.
4.  Such delegation is included in the contract amendment that is otherwise being filed to implement this provision.

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91456