Frequently Asked Questions

Under section 438.370, the enhanced match of 75 percent is available for the EQR-related activities described in section 438.358 if all of the following conditions are met:

• The EQR activity is performed on a managed care organization (MCO) by an entity meeting the requirements of a qualified EQRO in section 438.354 or its subcontractor;
• The activity is performed pursuant to a contract approved by CMS; and
• The activity is performed in accordance with a protocol issued by CMS.

FFP at the 50 percent matching rate is available for mandatory and optional EQR-related activities for PIHPs, PAHPs, and affected PCCM entities, regardless of whether the activities were conducted by an EQRO or another entity. FFP at the 50 percent matching rate is also available for EQR and related activities performed for MCOs that are conducted by an entity that is not a qualified EQRO. This is a change from previous regulations, under which the enhanced match was available for EQR of PIHPs to the same extent as MCOs. This provision took effect May 6, 2016.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94646

Regardless of whether an EQRO contract is approved before or after May 6, 2016, the change in FFP for EQR-related activities was effective May 6, 2016 for expenditures incurred by the state on or after May 6, 2016. Per general CMS-64 claiming principles, a state incurs an expenditure that may be claimed on the CMS-64 on the date the state pays the EQRO for the completed performance of the contracted EQR-associated activity.

The change to the FFP match rate for expenditure reporting takes effect in the middle of a quarter, which means that states must ensure that claims for expenditures for EQR activities affected by the change in FFP which were paid before May 6th and claims for expenditures which were paid on or after May 6th are reported separately. For only the quarter ending June 30, 2016, the CMS-64 EQRO Line 17 will allow states to report state expenditures associated with PIHP EQRO activities paid prior to May 6, 2016 and claim the enhanced 75 percent match. State expenditures associated with PIHP EQRO activities paid on or after May 6th must be claimed at the 50 percent matching rate.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94651

CMS expects to first issue revised protocols for the current mandatory and optional EQR-related activities in the Fall of 2017. We expect to issue the protocol for the new mandatory EQR activity relating to the validation of network adequacy later in 2017 or early 2018. States will have up to one year from the publication of the protocol to implement the new mandatory EQR activity.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94656

For questions related to state expenditure reporting and claiming instructions for EQR activities, please contact your CMS regional office financial representative. For specific external quality review questions, including what activities qualify for enhanced match, please contact the Division of Quality and Health Outcomes at ManagedCareQualityTA@cms.hhs.gov.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94666

As contained in the MECT standard RFP/contract language required by CMS, CMS does not cover activities that the state may require of the IV&V contractor during ongoing O&M. However, as Medicaid is moving away from monolithic single applications, it is expected that states will continuously update and replace modules in their enterprise. Therefore, IV&V should always have a role to ensure successful integration and testing.

FAQ ID:94881

If an organization is performing another role (such as systems integrator, PMO, quality assurance, etc.) on the MMIS or E&E project, it may not perform the IV&V function on the same project. A state may contract the same vendor to perform the IV&V role for both its E&E and MMIS projects.

FAQ ID:94886

To reduce potential conflict of interest, CMS is ensuring that states are arranging IV&V services through contracts that should be owned outside of the agency that owns the MMIS or E&E project. The oversight organization for the IV&V contractor should not be involved in oversight of the development effort, a stakeholder in the business implementation, or the DDI contractor. The IV&V contract monitor should be aware of system development problem solving, reporting, and contractor management. This contract oversight provides true independence between the IV&V contractor and system development teams. This requirement is consistent with other HHS agencies' practices and industry best practices.

FAQ ID:94891

CMS encourages states to reuse modular solutions as much as possible. If a state can reuse a modular solution from another state with minimal changes or customization, CMS will work with the state to streamline the certification process as much as possible to leverage knowledge of the reused solution. However, CMS will still require a certification decision for each state implementation of reused solutions to ensure compliance with federal regulations.

FAQ ID:94896

All the criteria in the checklists (MITA, MMIS or Custom) are the same. The difference between checklists is the criteria organization within the checklists. If the services solution is innovative, unique, or an unconventional approach, then the custom checklist approach might be appropriate. The RO will work with the state and vendors to decide which checklist set is best suited for the state's certification. Both service and traditional-type solutions need to meet all certification criteria to ensure compliance with federal regulations.

FAQ ID:94901

Yes, CMS will support the costs for this kind of MMIS transition. We encourage states to ensure that both the current vendor's and new solutions provider's contracts account for this transition period and address a prorating of cost during this time. States should minimize the costs of transition by performing due diligence on the anticipated spending. The legacy system provider should be compensated for its role in ensuring a smooth transition, with a ramp-down of other operational costs. The new solutions provider should have deliverables in its contract that speak to the soft launch or phased launch approach, with an uptick in operational costs as the transition progresses.

FAQ ID:94906