Frequently Asked Questions

The regulation only prohibits insurance policies that would be sold ""in conjunction with"" enrollment in the Medicaid managed care plan. Section 438.104 alone does not prohibit a Medicaid managed care plan from providing information about a Qualified Health Plans (QHP) to potential enrollees who could enroll in such a plan as an alternative to the Medicaid managed care plan due to a loss of Medicaid eligibility or to potential enrollees who may consider the benefits of selecting an Medicaid managed care plan that has a related QHP in the event of future eligibility changes. However, Medicaid managed care plans should consult their contracts and the State Medicaid agency to ascertain if other provisions exist that may prohibit or limit such activity.

Section 438.104(b)(1)(iv) implements a provision in section 1932(d)(2)(C) of the Social Security Act, titled ""Prohibition of Tie-Ins."" In promulgating regulations implementing this provision, CMS clarified that we interpreted it to preclude tying enrollment in the Medicaid managed care plan with purchasing (or the provision of) other types of private insurance. We do not intend the statutory prohibition of tie-ins to apply to a discussion of a possible alternative to the Medicaid managed care plan, which a QHP could be if the consumer is determined to be not Medicaid eligible or loses Medicaid eligibility.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)

FAQ ID:94351

States are encouraged to review their managed care contracts to clearly identify the legal entity with which they are contracted for Medicaid coverage since federal Medicaid managed care regulations do not address this aspect of contracting. If the party to the contract is an entity (such as a parent company) that has a contract with a state Medicaid agency to provide benefits as a Medicaid managed care plan and is also a QHP issuer, then some contractual provisions may apply to both. Although the federal Medicaid regulations do not apply to a QHP issuer or QHP, state law, regulation, or contract language may have implications for the QHP issuer. If changes are needed to narrow the scope of the contract to apply only to the Medicaid managed care plan, we encourage states to make those changes so as to ensure consistent understanding and application of the Medicaid contract terms.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)

FAQ ID:94371

Yes. Responding to direct questions from consumers is not generally a violation of 42 CFR 438.104. Proactive consumer inquiries to a health plan for information about coverage options, benefits, or provider networks is no different than a consumer obtaining information from the health plan's website. So long as the limits on marketing are satisfied and respected (e.g., the information is accurate and does not mislead, confuse or defraud beneficiaries or the state Medicaid agency), responding to direct questions from potential enrollees with accurate information is not prohibited.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)

FAQ ID:94391

There is no provision in 42 CFR 438.104 specifically addressing a Medicaid managed care plan's outreach to enrollees for eligibility purposes; therefore, it depends on the Medicaid managed care plan's contract with the state Medicaid agency. The federal regulation at 42 CFR 438.104 defines marketing as ""any communication, from an [Medicaid managed care plan] to a Medicaid beneficiary who is not enrolled in that entity, that can reasonably be interpreted as intended to influence the beneficiary to enroll in that particular [Medicaid managed care plan's] Medicaid product, or either to not enroll in, or to disenroll from, another [Medicaid managed care plan's] Medicaid product."" So long as information and outreach about the eligibility renewal process is neither directed to beneficiaries who are not enrolled with that Medicaid managed care plan, nor intended to influence the beneficiary to enroll in that particular Medicaid managed care plan-or to not enroll in, or disenroll from another Medicaid managed care plan-the activity is not within the scope of 42 CFR 438.104. Materials and information that purely educate an enrollee of that Medicaid managed care plan on the importance of completing the State's Medicaid eligibility renewal process in a timely fashion would not meet the federal definition of marketing. However, Medicaid managed care plans should consult their contracts and the state Medicaid agency to ascertain if other provisions exist that may prohibit or limit such activity.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)

FAQ ID:94396

The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.

FAQ ID:92231

The state should complete one template each for the DRG and per diem UPL calculations and these should be placed in one file. The state should also include a summary worksheet in the same file that shows the UPL gap for each ownership category (state government owned, non-state government owned, and private). States should include all necessary supporting documentation.

FAQ ID:92276

The total UPL gap by ownership category can be shown by inserting a new tab in the file with these calculations, unless a summary worksheet is already included in the workbook. If there are any questions about how to add this tab, please reach out to your CMS Regional Office or send a follow-up question (with your template) to the UPL mailbox and additional guidance will be provided.

FAQ ID:92281

When a Medicare provider number is not available, such as for some nursing facilities, the state should populate variable 112 using the acronym NMC, which stands for "Not Medicare Certified". Adding this information will help to clearly identify the facility's status.

FAQ ID:92286

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

A state may report adjustments by using the following variables: Adjustments to Medicare Per Diem #1 - Variable 212.1 and Adjustments to Medicare Per Diem #2 - Variable 212.2 for the Medicare Per Diem and Adjustment to Medicaid Per Diem #1 - Variable 314.1 and Adjustment to Medicaid Per Diem #2 - Variable 314.2 for the Medicaid Per Diem. A state may report more than one adjustment under a single variable. For example, if the state has three adjustments to their Medicaid per diem, one of these adjustments can be reported in variable 314.1 and the other two adjustments can be added together and reported in variable 314.2. When reporting any adjustment, the state must provide a detailed description of the adjustment(s) in the notes tab.

FAQ ID:92296