Frequently Asked Questions

If a woman indicates on an initial application that she is pregnant, she should be enrolled in Medicaid coverage as a pregnant woman, rather than in the new adult group. However, as stated in the preamble to the March 23, 2012 Medicaid and CHIP Eligibility & Enrollment final rule , states are not required to track the pregnancy status of women already enrolled through the new adult group. Women should be informed of the benefits afforded to pregnant women under the state's Medicaid program and if a woman becomes pregnant and requests a change in coverage category, the state must make the change if she is eligible.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)

FAQ ID:92151

If a woman is enrolled in a group for pregnant women, before the end of the post-partum period, as specified in the definition of "pregnant woman" at 42 CFR 435.4, the state Medicaid agency will need to re-evaluate the woman's eligibility for other groups, including the lowincome adult group and advance payment of premium tax credits through the Marketplace. Our regulations at 42 CFR 435.916 explain the requirements for states in connection with renewals of eligibility or determinations of ineligibility based on a change in circumstances. The procedures outlined in the regulation are intended to promote continuity of coverage.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)

FAQ ID:92161

No, CMS does not require any particular starting point within the fiscal year for the UPL demonstrations. This allows states the flexibility to develop UPL demonstrations that are tied to the provider payment periods described in the state plan payment methodologies for each service. For instance, if a state submits a state plan amendment to update provider payments as of October 1 of each year, the state would document that the SPA changes comply with the UPL for the period 10/1 - 9/30 of that payment year. The UPL must represent the entire payment year. Since UPL demonstrations usually rely on historic data that is projected into a payment year, this is consistent with past practices.

FAQ ID:92226

Variable 408 (Adjustment to the UPL Gap) is intended to allow states to report adjustments to their UPL gap, to the extent that these adjustments are not accounted for in other variables. Here, states could report broad-based increases or reductions in payment, such as a Medicaid volume adjustment for managed care expansion. The source of values input into variable 408 may differ by state. Whenever a state reports data in variable 408 it must include a comprehensive note describing the adjustment.

FAQ ID:92301

CMS plans to provide technical assistance on transition plans to States through the State Operations and Technical Assistance Team (SOTA) calls and through other calls with the State. We will also be providing additional guidance about the information that should be included in the transition plans. We will consider the transition plans that need to be submitted by the due date as living documents that are open to revision, and will continue to work with States to ensure a seamless transition in 2014 for beneficiaries and States.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 55.99 KB)

FAQ ID:93021

States wishing to continue the practice of disregarding parental income may do so by adopting coverage of a reasonable classification of individuals under age 21 under section 42 CFR 435.222. In this case, the "reasonable classification" would be pregnant individuals under age 21 (or under age 18, 19, or 20). The statutory income standard for this group would be based on the state's AFDC payment standard in effect in the state in July 1996. But if a state uses section 1902(r)(2) of the Act to disregard all income for this group, as has been done for other reasonable classifications of children (such as those in state foster care), there will be no determination of income required for eligibility, and MAGI-based income requirements will not apply.

To effectuate this option, states should submit a state plan amendment (SPA) to amend Attachment 2.2-A of the Medicaid state plan to cover a reasonable classification of pregnant individuals under age 21 under 42 CFR 435.222. The state should also amend Supplement 8a to Attachment 2.6-A to disregard all income for this new group.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92601

The Affordable Care Act provides significant federal support to ensure the availability of coverage to low-income adults. Enrollment caps limit enrollment in coverage on a first come, first serve basis. Periods of ineligibility delay or deny coverage for otherwise eligible individuals. These policies do not further the objectives of the Medicaid program, which is the statutory requirement for allowing section 1115 demonstrations. As such, we do not anticipate that we would authorize enrollment caps or similar policies through section 1115 demonstrations for the new adult group or similar populations.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93751

Demonstrations focused on changes to how health care services are delivered, such as the use of managed care, will not generally affect the state's matching rate. Please refer to our February 2013 FAQs (PDF, 135.35 KB), which provide further clarification on the two increased federal match rates: the newly eligible rate and the expansion state rate as well as the final FMAP rule published on April 2, 2013. Additionally, CMS issued two State Medicaid Director letters, on July 10, 2012, that provide guidance on how states can adopt integrated care models without the need for a section 1115 demonstration.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93756

Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94276

As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94361