Frequently Asked Questions

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

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

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

No, if a state's payment methodology describes payment at no more than 100 percent of the Medicare rate for the period covered by the UPL then it does not need to submit a demonstration using the template(s). To show the state has met the annual UPL demonstration reporting requirement it should make CMS aware that it is paying no more than the Medicare rate.

FAQ ID:92201

In order to receive the one percentage point FMAP increase, the state is required to submit a SPA with updated coverage pages. When a SPA is submitted with updated coverage pages, we will perform a review of the corresponding payment page(s). A state does not need to submit a SPA with revised payment pages, and conduct public notice, unless it wishes either to begin coverage and payment for these services or to change the existing payment rates (in other words, if the state already pays for the preventive services in some contexts, a payment SPA may not be needed if the state does not want to change the existing payment rate or methodology).

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FAQ ID:91516

The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.

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FAQ ID:91521

A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit. To claim that enhanced FMAP for managed care payments, CMS must review the methodology that the state intends to use to estimate the value of the preventive services benefit in its capitation rates.

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FAQ ID:91526

Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.

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FAQ ID:91531

No, fluoride varnish is not eligible for the one percentage point FMAP increase. In the future, if the United States Preventive Services Task Force (USPSTF) adds fluoride varnish to the A or B recommended preventive services, states will be required to cover the fluoride varnish with no cost-sharing. Per State Medical Director (SMD) letter #13-002, states should provide an assurance in the state plan indicating they have a method to ensure that, as changes are made to the USPSTF and the Advisory Committee on Immunization Practices (ACIP) recommendations, they will update their coverage and billing codes to comply with those revisions. As long as this assurance is in the state plan, states are not required to submit a state plan amendment each time the USPSTF or ACIP makes changes to their recommendations.

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FAQ ID:91536