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
When a state pays a provider at reconciled cost using Certified Public Expenditures during the period covered by the Upper Payment Limit (UPL) demonstration, how should the provider's data be treated?
The UPL limits payment to the Medicare rate or cost. Providers paid at reconciled cost may receive no more than their reconciled amount. As a result, states cannot attribute the “UPL room” from other providers to pay additional amounts to any provider paid at reconciled cost. Due to this payment limitation, states should not include any provider paid at reconciled cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at reconciled cost and confirm by provider use of either a Medicare cost report or Centers for Medicare & Medicaid Services-approved cost report template to identify allowed cost. Further, states must document the ownership status (state owned, non-state government owned, or private) of each provider.
FAQ ID:92436
SHARE URLHow does this durable medical equipment (DME) limit on federal financial participation (FFP) affect those states that are 90% managed care?
As we explained in the January 4, 2018 letter, only those items provided in the Medicaid program on a fee-for-service (FFS) basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the FFP limitation. If a state is 90% managed care the state would only have to show compliance or a demonstration with the 10% of FFS utilization and expenditures for the relevant DME items.
FAQ ID:93531
SHARE URLDo the managed care organizations (MCOs), who are contracted to provide services to our Medicaid clients, have to comply with the durable medical equipment (DME) limit on federal financial participation (FFP)?
So long as the MCOs are not paid on a fee-for-service (FFS) basis, MCOs are not covered under this statute or subject to the limit on FFP. Only the relevant DME items provided in FFS are included in this limit.
FAQ ID:93536
SHARE URLAre states that provide durable medical equipment (DME) through a managed care arrangement required to submit the reconciliation data?
Only those items provided in the Medicaid program on a fee-for-service basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the federal financial participation limitation.
FAQ ID:93541
SHARE URLCenters for Medicare & Medicaid Services is saying this durable medical equipment (DME) limit on federal financial participation is applicable only to fee for service (FFS). How about the Home and Community-Based Services (HCBS) waiver programs?
If the HCBS waiver includes FFS payments for DME, the state’s expenditures for DME would be subject to the limit.
FAQ ID:93546
SHARE URLProviders are permitted to charge a copay for a member's office visit. This visit may include a variety of services including preventive and non-preventive services. The State Medical Director (SMD) letter indicates the enhanced federal medical assistance percentage (FMAP) is available if cost-sharing is eliminated for preventive services. We believe this to mean that the doctor cannot collect a copay for any visit in which preventive services are provided, regardless of whether the majority of services provided during the visit are non-preventive services. We would like CMS verification.
If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.
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FAQ ID:92121
SHARE URLWhat materials does CMS require a state to submit as part of the Upper Payment Limit (UPL) Demonstration submission package?
The submission package consists of the completed templates and any supporting documentation needed to understand the UPL demonstration. This could include the completed Guidance document and supporting documentation (in Microsoft Excel with formulas included, not as a PDF) that is necessary to further explain a state's UPL demonstration, and a summary spreadsheet that aggregates the UPL gap for each of the ownership categories (state government owned, non-state government owned, and private).
FAQ ID:92236
SHARE URLWhen a state pays a provider at cost during the period covered by the Upper Payment Limit (UPL) demonstration, how should the provider's data be treated?
The UPL limits payment to the Medicare rate or cost. Providers paid at cost may receive no more than their reconciled amount. As a result, states cannot attribute the "UPL room" from other providers to pay additional amounts to any provider paid at cost. Due to this payment limitation, states should not include any provider paid at cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at cost and, therefore, excluded from the calculation of the UPL.
FAQ ID:92396
SHARE URLUnder section 4106 of the Affordable Care Act, is there a modifier to assist providers, payers and states in identifying preventive services?
The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
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FAQ ID:91991
SHARE URLUnder section 4106 of the Affordable Care Act, if the preventive service is bundled with other services, and the bundled service includes more than one preventive service, may the state allocate the bundled payment among the included services and claim the enhanced match for each of the preventive services? For example, in an annual exam, the physician provides both obesity counseling and alcohol misuse counseling. Can the state submit a claim for both the obesity counseling and the alcohol counseling?
It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.
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FAQ ID:91996
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