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
If a state needs to reduce durable medical equipment (DME) rates as a result of this requirement, is the state required to complete an Access Monitoring Review Plan as described in 42 CFR 447.203 and 447.204, which is required for state plan amendments that propose to reduce payments to Medicaid providers?
State Medicaid Director Letter #17-004 addressed this area by stating: “Reductions necessary to implement CMS federal Medicaid payment requirements (e.g., federal upper payment limits and financial participation limits), but only in circumstances under which the state is not exercising discretion as to how the requirement is implemented in rates. For example, if the federal statute or regulation imposes an aggregate upper payment limit that requires the state to reduce provider payments, the state should consider the impact of the payment reduction on access.” In addition, the long-standing policy of the Medicaid program has been that Medicare rates are sufficient to ensure access.
FAQ ID:93521
SHARE URLConsidering the differences between the Medicaid and Medicare populations, will limiting federal financial participation (FFP) for durable medical equipment (DME) cause hardship for people with disabilities in the Medicaid program?
We acknowledge that there are differences between the Medicare and Medicaid populations, but nothing in the policy guidance or statute compels states to reduce the items that states provide to people with disabilities under the state plan. As noted above, the statute does not expressly compel states to reduce the payment rates for DME. The statute limits the amount of money that the federal government will pay (i.e., FFP) for the relevant DME in the aggregate as compared with the relevant DME provided in the Medicare program. States retain the flexibility to make payments at rates that best serve the needs of their Medicaid beneficiaries.
FAQ ID:93526
SHARE URLCan a state review providers whose claims meet the 60 percent threshold and assume that those providers would be automatically eligible?
Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
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FAQ ID:94276
SHARE URLCMS clarified in the final rule for CMS 2370-F that, for out of state providers, the beneficiary's home state (e.g., state A) may defer to the determination of the physician's home state (e.g., state B) with respect to eligibility for higher payment. However, if states A and B receive different Medicare locality adjustments, which locality rate must be paid?
As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.
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FAQ ID:94361
SHARE URLWhen does the Centers for Medicare & Medicaid Services (CMS) plan to issue a correction to the mistake they noted during the call with Medicaid agencies regarding payment under CMS 2370-F at the lesser of a provider's billed charge or the Medicare rate?
The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.
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FAQ ID:94376
SHARE URLIf a physician presents a certificate for CMS 2370-F eligibility from one of the defined boards, can the certificate be used as the legal document verifying the physician's certification or does the State have to verify with the board that the physician is certified and that the presented certificate is still active and valid?
States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.
FAQ ID:92686
SHARE URLThe final rule for CMS 2370-F indicated that 100 percent Federal Financial Participation (FFP) is not available for stand-alone Children's Health Insurance Program (CHIP) plans. What criteria should be used to determine if a plan is a stand-alone CHIP plan? What agency will determine if a plan is a stand-alone CHIP plan?
The Center for Medicare & Medicaid Services (CMS) approves CHIP programs as stand-alone or Medicaid expansions. Information on whether or not a particular state operates a stand-alone or expansion program is available at http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Downloads/Map-CHIP-Program-Designs-by-State-.pdf (PDF, 120.65 KB).
FAQ ID:92696
SHARE URLFederally qualified health centers (FQHCs)/ rural health clinics (RHCs) which receive an encounter rate are excluded under the rule for CMS-2370 F. Are FQHCs/RHCs who are paid provider fee-for-service included in the increase?
FQHCs and RHCs are required by law to be paid at least prospective payment system (PPS) for core primary care services. Physician services are core FQHC and RHC services and, therefore, should not be reimbursed on a fee-for-service basis.
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FAQ ID:92701
SHARE URLIn our state, advanced practice nurses must have a collaborative practice agreement with a physician within 50 miles of their office. Under the collaborative practice agreement, a physician must review a certain percentage of the nurse's patient charts every 2 weeks. Such nurses bill independently using their own Medicaid number. Is the collaborative practice agreement enough documentation for an advance practice nurse, with at least 60 percent of services billed by the nurse for calendar year (CY) 2012 for
Increased payment is available for services provided by eligible physicians or for services provided under their personal supervision. This means that the physician accepts professional responsibility (and legal liability) for the services provided. It does not appear that the collaborative arrangement requires that the physician accept professional responsibility for each of the services provided by the nurses. Therefore, increased payment would not be available.
However, if the physician is required to accept professional responsibility for the services provided by the advanced practice nurses and the physician is eligible based on self-attestation to a specified primary care specialty designation supported by either appropriate Board certification or a 60 percent claims history, then increased payment would be available.
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FAQ ID:92706
SHARE URLIf the supervising physician does not self-attest to the physician specialty or subspecialty qualification under CMS 2370-F, can the physician supervise a mid-level provider? If the supervising physician self-attests to the 60 percent threshold, but not one of the defined specialty or subspecialty qualifications, can the physician supervise a mid-level?
The eligibility of services provided by mid-level/non-physician practitioners is dependent on 1) the eligibility of the physician and 2) whether or not the physician accepts professional responsibility for the services provided by the mid-level. As previously noted, physicians are eligible only if they first self-attest to a specified specialty designation and also to either being appropriately Board certified or having a 60 percent claims history.
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FAQ ID:92711
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