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 URLUnder CMS 2370-F, may states continue to use discounted reimbursement rates for out-of-state or out-of-network eligible primary care providers, which may be less than the Medicare rate, for calendar years (CYs) 2013 and 2014?
CMS acknowledges the customary practice of reimbursing out-of-state or out-of-network providers at a base rate minus a defined percentage. The applicable Medicare rate effectively becomes the ‘floor’ for payments to eligible providers for eligible services rendered in CYs 2013 and 2014. Health plans may pay above that rate but not below.
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FAQ ID:92131
SHARE URLUnder CMS 2370-F, CMS has indicated that the CMS-64 will be modified for states to report the expenditures that will receive the 100 percent federal medical assistance percentage (FMAP) for the increased expenditures for primary care services. Will the CMS-21 also be modified to report these expenditures for the CHIP Medicaid Expansion population?
No. The only expenditures that count against the CHIP allotment and must be reported on the CMS-21 are those related to the Medicaid rate in effect on July 1, 2009. The difference between those rates and the 2013 and 2014 Medicare rates eligible for 100 percent FMAP are Medicaid expenditures and are reported on the CMS 64.9.
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FAQ ID:92116
SHARE URLCan a contractor that acts on behalf of the Medicaid agency submit the Upper Payment Limit (UPL) demonstrations to CMS?
No, the information must be submitted by the State Medicaid Director (or designated state official).
FAQ ID:92246
SHARE URLHow should cost data reported for a partial year be treated either when one hospital acquires another hospital or a hospital ceases operation?
When a hospital acquires another hospital, the state should use all available data to determine the UPL and work with CMS to assure appropriate reporting. When a hospital ceases operation, the state should not annualize data if it does not cover a 12-month period.
FAQ ID:92391
SHARE URLHow is the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) different from other institutional UPLs?
Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.
FAQ ID:92416
SHARE URLIs the state required to report in the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) template the number of service days for Medicaid beneficiaries?
Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.
FAQ ID:92421
SHARE URLDo allergists qualify for higher Medicaid payment under the CMS 2370-F rule?
CMS recently received information from the American Board of Medical Specialties attesting that the American Board of Allergy and Immunology (ABAI) is an ABMS-recognized sub-discipline of the American Board of Pediatrics and the American Board of Internal Medicine.
Specifically, the ABAI is a conjoint board of the American Board of Pediatrics (ABP) and the American Board of Internal medicine (ABIM). All physicians certified by the Board of Allergy and Immunology must first be board certified by either ABP or ABAI. Medical specialists certified by the Allergy and Immunology Board remain subspecialists of Internal Medicine and Pediatrics. However, it is possible that some holders of a certificate from ABAI will not have a current certificate in Internal Medicine or Pediatrics because some diplomats of the ABP and ABIM who hold subspecialty certificates are not required to maintain their primary certificates. The ABMS was concerned that these diplomats might be excluded from eligibility for higher payment under a strict interpretation of the rule even though they do act as their patients' primary care provider in many cases and urged that CMS formally recognize that diplomats of ABAI are, in fact subspecialists in Internal Medicine and Pediatrics and eligible for higher payment up to the Medicare rate.
Based on this information, CMS agrees that allergists are eligible for higher payment under the rule.
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FAQ ID:91486
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