Frequently Asked Questions

"Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment Final Rule" (CMS-2334-F), published in the Federal Register on 7/15/2013, conformed the regulatory definition of preventive services at § 440.130(c) with the statute relating to the issue of who can be providers of preventive services. Per the final rule, effective 1/1/2014, preventive services may be recommended by a physician or other licensed practitioner. Therefore, unlicensed practitioners will be able to furnish preventive services (including the services mentioned in section 4106), based on the recommendation of a physician or other licensed practitioner, according to the provider qualifications established by each respective state, within broad federal parameters. In order for states to receive the one percentage point federal medical assistance percentage (FMAP) increase for unlicensed practitioners, it is likely that a state plan amendment updating section (13)(c) of the state plan will be necessary. Please refer to the preventive service CMCS Informational Bulletin issued on November 27, 2013 for additional information regarding adding unlicensed practitioners to the preventive services section of the state plan.

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

FAQ ID:91676

While section 4106 of the Affordable Care Act states that USPSTF grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration must be covered to secure the one percentage point FMAP increase, it is incumbent upon state Medicaid agencies to continue to work with, and communicate to, providers concerning state-specific systems and appropriate codes. The information provided by the American Medical Association in the below link (the CPT Code Pocket Guide: Preventive services with cost-sharing waived) can be used as a starting point in creating a cross-walk from the USPSTF and ACIP recommended codes, but it is not all-inclusive.

In addition, the October 2012 State Health Official (SHO) letter, gave the below web site address for HCPCS codes effective for service dates on or after January 1, 2012, and contacts within CMS for questions regarding HCPCS codes.

http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html 

Supplemental Links:

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

FAQ ID:91686

While there is no deadline given in the provision for states to create public awareness campaigns to inform Medicaid beneficiaries of the preventive services covered in their state, CMS looks forward to partnering with states to develop innovative approaches. CMS is required to prepare a periodic Report to Congress including "summaries of the states' efforts to increase awareness of coverage of obesity-related services," and the next report will be submitted by January 1, 2014. As such, CMS is gathering information about states' efforts to inform the 2014 report. States may email MedicaidCHIPPrevention@cms.hhs.gov to submit information about preventive and obesity-related services public awareness efforts in their communities.

Supplemental Links:

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

FAQ ID:91491

Yes, a state may submit a SPA at any time. The one percentage point increase in federal medical assistance percentage (FMAP) per the requirements outlined in section 4106 of the Affordable Care Act does not have an end date.

Supplemental Links:

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

FAQ ID:91511

A Non-Medicaid Reimbursed amount is any amount paid on a claim by parties other than Medicaid (e.g., other federal coverage, co-pay, private insurance). If a state receives Federal Financial Participation (FFP) for any part of a claim for a Covered Outpatient Drug (COD), that portion of the claim is included in the Medicaid Reimbursed amount. If a state does not receive FFP for any part of a rebate-eligible claim, then the amount of the claim is included in the Non-Medicaid Reimbursed amount.

FAQ ID:91981

The sum of the “Medicaid Amount Reimbursed” and the “Non-Medicaid Amount Reimbursed” fields should generally equal the Total Amount Reimbursed on a National Drug Code (NDC) by NDC basis; however, these new fields were implemented beginning with the fourth quarter of 2007 and are optional for the states to report prior to that time. Therefore, for quarters earlier than fourth quarter 2007, there may be some large discrepancies between the Total Amount Reimbursed and the sum of the Medicaid Amount Reimbursed and the Non-Medicaid Amount Reimbursed because the Non-Medicaid Amount Reimbursed is often not present for those earlier quarters. Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.

FAQ ID:91986

Amounts reimbursed by Medicaid are pre-rebate, not net of rebates.

FAQ ID:92001

"Units Reimbursed" are the number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state or, for MCO drugs, the number of units dispensed during the Quarter/Year. For more specific information, you may contact either the Drug Manufacturer or State via the contact lists.

FAQ ID:92016

States are required to submit their utilization data to CMS within 60 days of the end of the rebate period.

FAQ ID:92026

Per section 1927 of the Act, initial submissions of quarterly state utilization data are due to CMS within 60 days of the end of each rebate period. If a state fails to report utilization data in the quarter that it was dispensed, the state must submit initial utilization data for the most recently closed quarter as well as adjustments/corrections to any previously reported utilization data.

FAQ ID:92036