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
States enact laws to comply with section 1902(a) (25) (I)(i) of the Social Security Act and must require health insurers to provide, upon the request of the state, information to determine during what period Medicaid beneficiaries may be (or may have been) covered by the health insurer and the nature of the coverage that is or was provided.
This information includes, at a minimum, four (4) data elements: the insured's name, address, group or member ID number, and periods of coverage. State laws determine exactly what information is required to be submitted by the health plans. Health plans are to provide these files to state Medicaid programs so that these programs can determine whether any third party payers are liable for the medical items and services that were, or will be, delivered to a Medicaid beneficiary. In essence, the point of the information gathering is to ensure that Medicaid benefits are paid correctly.
In the case of health insurers who contract with a pharmacy benefit manager (PBM) or other third party administrator (TPA) to administer the plan, states also will need to require that such insurers provide the PBM or TPA with such information as may be necessary to enable that entity to furnish the state with the prescribed data, or deal with such inquiries directly without the aid of their PBM or TPA.
Supplemental Links:
Date: September 11, 2014
Topics:
Medicaid Coordination of Benefits
Subtopics:
General Information
FAQ ID: 94166
The Deficit Reduction Act of 2005 (DRA) requires states to have laws in effect that require health insurers to honor claims submitted by the Medicaid agency within three years of the date of service.
Supplemental Links:
Date: September 11, 2014
Topics:
Medicaid Coordination of Benefits
Subtopics:
General Information
FAQ ID: 94181
State Medicaid agencies and their business associates can use the data obtained pursuant to the process established under section 1902(a)(25)(I) of the Social Security Act and applicable state laws, as permitted or required by law. This should include the coordination of payments for services covered under the Medicaid state plan and actions to ensure that correct payment amounts are made under the Medicaid program and that mistaken payments are recovered. If the appropriate legal relationships are established (e.g., business associate agreements under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)), we expect that the data could be released to entities working under contract with a state agency for use in activities such as claims adjudication activities, or for the purpose of recovering improper Medicaid payments. State Medicaid agencies must have procedures in place to ensure that the privacy of individuals is appropriately protected, and that information concerning applicants and beneficiaries is protected in accordance with the requirements of 42 CFR Part 431 Subpart F and the regulations at 45 CFR Parts 160 and 164, which were promulgated under HIPAA and Health Information Technology for Economic and Clinical Health (HITECH) Act.
Supplemental Links:
Date: September 11, 2014
Topics:
Medicaid Coordination of Benefits
Subtopics:
General Information
FAQ ID: 94186
Generally, the purpose of the 1202 payment increase is to directly benefit physicians performing primary care services. In the instance of salaried physicians, including those working for clinics or other employing organizations that bill on the Medicaid physician fee schedule, this could come in the form of an increased salary. Alternatively, where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.
Date: April 14, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 91081
To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.
Date: April 14, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 91086
States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.
Date: April 14, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 91091
Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.
Date: April 14, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 91096
A state is not required to cover all of the primary care service billing codes if it did not previously do so. Rather, to the extent that it reimburses physicians using any of the billing codes specified in the final rule, the state must pay at the Medicare rate in the calendar years (CYs) 2013 and 2014.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91346
A state may not add any of the eligible service codes solely for the purpose of obtaining enhanced federal matching funds. For example, a state may not eliminate a code currently in use and attempt to substitute it with another Evaluation and Management (E&M) code. However, we recognize that a handful of codes have been added to the E&M code set since 2009. States which added those codes to their fee schedules will receive higher match for those services.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91351
Under Medicare and Medicaid principles, payment is to be made at the lower of provider charges or the rate, which in this case is the applicable Medicare rate. This language was inadvertently omitted from the final rule. The Center for Medicare & Medicaid Services (CMS) is processing a technical correction to the regulatory text at 42 CFR 447.405 to restore this language.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91356