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 facility has been in operation for the dates of service covered by the Upper Payment Limit (UPL) demonstration, can a state demonstrate the UPL by using less than 12 months of data?
In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.
FAQ ID:92446
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 URLHow should Upper Payment Limit (UPL) supplemental payments be entered in the template?
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
SHARE URLWhen a state pays at or less than the Medicare rate is it required to submit an Upper Payment Limit (UPL) demonstration using the template(s)?
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
SHARE URLThe state is under the impression that they only need to update the 3.1-A coverage pages for preventive services to claim the 1% federal medical assistance percentage (FMAP) increase under section 4106 of the Affordable Care Act. Does the state need to update their reimbursement pages as well to provide the required assurances?Can you please advise if CMS will require public notice in addition to the state plan amendment (SPA) for the 1% FMAP increase to take effect?
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
SHARE URLUnder what portion of the state plan should the state add the Affordable Care Act section 4106 information?
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
SHARE URLDoes a state that has both a fee-for-service (FFS) and a managed care delivery system, get the 1% federal medical assistance percentage (FMAP) increase when just the FFS benefit is amended or would the state have to concurrently amend its managed care authority document (state plan amendment (SPA), waiver or 1115 demonstration project) to get the 1% FMAP increase under section 4106 of the Affordable Care Act?
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
SHARE URLAccording to the United States Preventive Services Task Force (USPSTF) methodology "The Task Force also aims to update topics every five years, in order to keep recommendations in the Task Force library current according to criteria established by the National Guideline Clearinghouse. Under section 4016 of the Affordable Care Act, does the requirement of covering and claiming increased federal financial participation (FFP) for USPSTF A and B recommendations apply only to recommendations that are new, updated, or reaffirmed within the past five years?
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
SHARE URLAre fluoride treatments (also known as fluoride varnishes) eligible for the one percentage point increase in federal medical assistance percentage (FMAP) under section 4106 of the Affordable Care Act?
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
SHARE URLUnder section 4106 of the Affordable Care Act, the list of United States Preventive Services Task Force (USPSTF) preventive services describes services as being available for persons based on their sex and age range. For example: Abdominal aortic aneurysm screening (men): The USPSTF recommends one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked. Are states required to follow the USPSTF grade A and B recommendations on age, gender and smoking status in order to claim the one percentage point federal medical assistance percentage (FMAP) increase for a particular service?Since some recommendations have start and stop ages, are states required to perform age edits on each service for each individual?
States may only claim the one percentage point FMAP increase on services that adhere to the USPSTF grade A and B recommendations on age, gender, periodicity and other criteria as indicated in the summary of recommendations. For instances where the USPSTF grade A and B recommendations have expanded age, gender or periodicity levels due to clinical considerations, practitioners should document in the patient's medical record the necessity for exceeding the grade A and B recommendations, and states may claim the one percentage point FMAP increase. When billing for these services, payers may want to use modifier 33 to identify services that meet the criteria for the USPSTF grade A and B recommendations. Pursuant to page 2 of State Medical Director (SMD) letter #13-002, states should have a financial monitoring procedure in place to ensure proper claiming for federal match.
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FAQ ID:91541
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