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
Under CMS 2370-F, are the services of "physician extenders" (defined as physicians who provide services in support of eligible physicians) eligible for higher payment when an eligible primary care specialist bills for their services? Examples of "physician extenders" include neurologists, OB/GYNs, pathologists, anesthesiologists and surgeons who provide services to the patients of eligible physicians.
No. The only services that qualify are those provided directly by physicians (or by non-physician practitioners that they supervise) who self-attest to an eligible primary care designation and whose attestation is supported by evidence of board certification or claims history. Physicians who do not qualify on their own merits cannot receive higher payment by having an eligible physician bill on their behalf. As previously noted, physicians must accept professional responsibility/liability for the services provided by non-physician practitioners under their supervision.
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FAQ ID:93911
SHARE URLUnder CMS 2370-F, are eligible E&M and vaccination codes that are covered by managed care health plans but not under the Medicaid state plan eligible for reimbursement at the enhanced Medicare rate?
No. The only codes that are eligible for reimbursement at the Medicare rate as specified under the final rule are those eligible codes that are identified under the Medicaid state plan. Additional E&M or vaccination administration codes that are being “covered” by a health plan but that are not identified in the state plan cannot be reflected in the rates.
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FAQ ID:93916
SHARE URLThe CMS 2370-F final rule specified that states will need to recoup the enhanced payments made to non-eligible providers identified through the annual statistically valid sample. Must health plans follow the same procedure for non-eligible providers
States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in some states, this sample will include both fee-for-service (FFS) and managed care providers.
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FAQ ID:93921
SHARE URLAs we are working to implement ACA 1202, we found that we have to pay to access the American Board of Medical Specialties (ABMS) website because use of the website for business or certification is strictly prohibited. Is CMS aware of what other states are doing? Is there some other way to access this information without paying?
The state has two options: (1) it may claim this cost as an administrative expense of the Medicaid program; or, (2) it may require physicians to provide this documentation when they self-attest.
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FAQ ID:93926
SHARE URLWhat specific plans and timeline do you have for enacting the reforms and flexibility options for Medicaid that you spoke of in 2009? When can states give further input on the needed reforms?
CMS continues to work closely with states to provide options and tools that make it easier for states to make changes in their Medicaid programs to improve care and lower costs. In the last six months, we have released guidance giving states flexibility in structuring payments to better incentivize higher-quality and lower-cost care, provided enhanced matching funds for health home care coordination services for those with chronic illnesses, designed new templates to make it easier to submit section 1115 demonstrations and to make it easier for a state to adopt selective contracting in the program, and developed a detailed tool to help support states interested in extending managed care arrangements to long term services and supports. We have also established six learning collaboratives with states to consider together improvements in data analytics, value-based purchasing and other topics of key concern to states and stakeholders, and the Center for Medicare and Medicaid Innovation has released several new initiatives to test new models of care relating to Medicaid populations. Information about these and many other initiatives are available on Medicaid.gov. We welcome continued input and ideas from states and others. States can implement delivery system and payment reforms in their programs whether or not they adopt the low-income adult expansion. With respect to the expansion group in particular, states have considerable flexibility regarding coverage for these individuals. For example, states can choose a benefit package benchmarked to a commercial package or design an equivalent package. States also have significant cost-sharing flexibility for individuals above 100% of the federal poverty level, and we intend to propose other cost-sharing changes that will modernize and update our rules.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94606
SHARE URLWill the federal government support options for the Medicaid expansion population that encourage personal responsibility?
Yes, depending on its design. We are interested in working with states to promote better health and health care at lower costs and have been supporting, under a demonstration established by the Affordable Care Act, state initiatives that are specifically aimed at promoting healthy behaviors. Promoting better health and healthier behaviors is a matter of importance to the health care system generally, and state Medicaid programs, like other payers, can shape their benefit design to encourage such behaviors while ensuring that the lowest income Americans have access to affordable quality care. We invite states to continue to come to us with their ideas, including those that promote value and individual ownership in health care decisions as well as accountability tied to improvement in health outcomes. We note in particular that states have considerable flexibility under the law to design benefits for the new adult group and to impose cost-sharing, particularly for those individuals above 100% of the federal poverty level, to accomplish these objectives, including Secretary-approved benchmark coverage.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94611
SHARE URLWill CMS approve global waivers with an aggregate allotment, state flexibility, and accountability if states are willing to initiate a portion of the expansion?
Consistent with the guidance provided above with respect to demonstrations available under the regular and the enhanced matching rates, CMS will work with states on their proposals and review them consistent with the statutory standard of furthering the interests of the program.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94616
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