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
Should the rate of required exclusions be reported with the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure's Part 1 performance rate?
The measure excludes plan members who are not ambulatory from the measure rate, but it is not necessary to report the number of members excluded with the measure’s performance rate.
FAQ ID:89006
SHARE URLIs a specific screening tool required for the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure?
No, a specific screening tool is not required for this measure. However, potential screening tools may include the Morse Fall Scale and timed Get-Up-And-Go test.
FAQ ID:89011
SHARE URLWhat is the difference between a screening (Part 1) and a risk assessment (Part 2) for the purposes of calculating the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure?
A falls screening is an evaluation of whether a Managed Long Term Services and Supports plan member has experienced a history of falls and/or problems with balance or gait. A falls risk assessment includes a balance/gait assessment and one other assessment component and should only be performed for members with a documented history of falls (at least two falls or one fall with injury in the past year).
FAQ ID:89016
SHARE URLHow will states and providers know which primary care services will be paid at the higher rates under CMS 2370-F?
Regulation at 42 CFR 447.000(c)(1) and (2) specifies Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, or their successor codes.
FAQ ID:92126
SHARE URLAre there any circumstances that would allow a state to apply the same Upper Payment Limit (UPL) demonstration to multiple years?
When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.
FAQ ID:92221
SHARE URLOur state uses multiple cost centers (routine and ancillary) in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple cost centers?
Yes, the templates allow the use of multiple cost centers. For example, if the state uses a cost methodology for ancillary services and a per-diem methodology for routine services, the state will complete one cost template and one per-diem template in order to account for these two cost centers. Every hospital would be featured in each of the two templates; however, to differentiate their provider information, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the cost template as 123456-A and in the per diem template as 123456-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number. If there are multiple cost centers under either the cost or per-diem methodology, the state would separate out the cost centers within their respective templates. Each cost center should be associated with only one appended letter and these should be described in the notes tab. When using multiple cost centers, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.
FAQ ID:92261
SHARE URLOur state covered institutions for mental disease (IMD) under the inpatient hospital and nursing benefit. Should we conduct a separate UPL for these facilities?
No, facilities that are licensed, covered, and paid under the Medicaid state plan as inpatient hospital or nursing facilities should be included in the UPL calculated for those services. There is no regulatory requirement to conduct separate calculations for designated facility "types" within each of the applicable service categories. States do not need to provide separate UPL demonstrations for IMDs covered under the inpatient hospital or nursing facility services benefit.
FAQ ID:92381
SHARE URLOur understanding of the CMS 2370-F rule is that advanced practice clinicians are eligible for the increased payment as long as they are working under the personal supervision of an eligible physician; eligible meaning the supervising physician is also eligible for the increased payment.
The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.
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FAQ ID:92106
SHARE URLWho can I contact for technical assistance questions, as well as information about state Medicaid prevention efforts and section 4004(i) of the Affordable Care Act?
Technical assistance questions, as well as information about state Medicaid prevention efforts, can be directed to: MedicaidCHIPPrevention@cms.hhs.gov and/or Deirdra Stockmann, 410-786-2433.
Supplemental Links:
FAQ ID:91501
SHARE URLWill retroactive provider payments by health plans - necessitated by the State's retroactive payment of the higher rates to health plans - be subject to timely claims filing requirements in 42 CFR 447.46? If so, may states impose liquidated damages or other penalties on health plans for violating those requirements?
Any retroactive payments made to providers in order to ensure that eligible providers receive the applicable Medicare rate for eligible services will not be considered claims subject to the requirements in 42 CFR 447.46.
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FAQ ID:91411
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