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
Do states need to track people enrolled in the adult group who become pregnant? If a woman indicates on the application she is pregnant, do states need to enroll her as a pregnant woman if she is otherwise eligible for the adult group? Would there be a need to track pregnancy if the benefits for both groups are the same?
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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)
FAQ ID:92151
SHARE URLIf a woman moves from the adult group under 1902(a)(10)(A)(i)(VIII) to the pregnant woman group, are states then required to move former pregnant women from the pregnant women eligibility group back to the adult group when the post-partum period ends?
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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)
FAQ ID:92161
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.
Supplemental Links:
FAQ ID:92121
SHARE URLNow that Upper Payment Limit (UPL) demonstrations are submitted to a central e-mailbox, will the CMS Regional Office still have a role in reviewing UPL demonstrations or will the review be performed by the Central Office?
The Regional Office will continue to review state UPL demonstrations and states will continue to work with the CMS Regional Offices as a first point of contact concerning their UPL demonstrations.
FAQ ID:92256
SHARE URLIf we complete multiple inpatient templates for Diagnosis Related Groups (DRG) and per diem, should they be in the same file or separate files? Should there be a summary of all the inpatient Upper Payment Limits (UPLs) showing grand totals?
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
SHARE URLThe Inpatient Hospital Services (IPH), Outpatient Hospital Services (OPH), and Nursing Facility (NF) templates do not include fields to sum the Upper Payment Limit (UPL) gap by ownership category (private, Non-State Governmental Organization (NSGO), State Government Ownded (SGO). How should these totals be presented in the template?
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
SHARE URLOne of the required fields in the Nursing Facility template is the Medicare Provider Number (Medicare Certification Number - Variable 112), but not all facilities are Medicare certified. How should data be entered for these facilities since it is a required field?
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
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 URLHow should more than two adjustments to the per diem be addressed in the nursing facility template for both Medicare and Medicaid Per Diem?
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
SHARE URLWhat are examples of what would be appropriate adjustments to the Upper Payment Limit (UPL) in step 9 (Adjustments to the UPL and UPL Gap Calculation) (field 408) of the template?
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
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