Frequently Asked Questions

As we explained in the January 4, 2018 letter, only those items provided in the Medicaid program on a fee-for-service (FFS) basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the FFP limitation. If a state is 90% managed care the state would only have to show compliance or a demonstration with the 10% of FFS utilization and expenditures for the relevant DME items.

FAQ ID:93531

So long as the MCOs are not paid on a fee-for-service (FFS) basis, MCOs are not covered under this statute or subject to the limit on FFP. Only the relevant DME items provided in FFS are included in this limit.

FAQ ID:93536

Only those items provided in the Medicaid program on a fee-for-service basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the federal financial participation limitation.

FAQ ID:93541

If the HCBS waiver includes FFS payments for DME, the state’s expenditures for DME would be subject to the limit.

FAQ ID:93546

No, states that already have submitted their 2018 (07/01/2017 - 06/30/2018) inpatient hospital, outpatient hospital, or nursing facility services UPL demonstrations will not have to resubmit using the templates. In that instance, CMS will populate the templates using data already submitted by the state.

FAQ ID:92211

States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.

FAQ ID:92251

In an assessment model, the Federally-Facilitated Marketplace will not make a final Medicaid determination. Instead, the Federally-Facilitated Marketplace will transmit the account to the Medicaid or CHIP agency when they have evaluated the individual and identified him or her as Medicaid or CHIP eligible, and the Medicaid or CHIP agency will make the formal determination. In a determination model, the Medicaid or CHIP agency delegate the authority to make determinations to the Federally-Facilitated Marketplace. In both an assessment and determination model, as described in more detail in 42 CFR section 435.1200, the Federally-Facilitated Marketplace will utilize the same set of eligibility criteria, including selected state-specific options and standard verification procedures. If the state agency chooses the determination model, it must accept the Federally-Facilitated Marketplace determination as final. If the state chooses the assessment model, it must accept findings made by the Federally-Facilitated Marketplace relating to a criterion of eligibility, as long as the Federally-Facilitated Marketplace applies the same policies and verification procedures as those the state agency employs. In a state with a separate CHIP agency, the state Medicaid and CHIP agencies can make different choices allowing the Federally-Facilitated Marketplace to make an assessment or determination. States must choose either the assessment or determination model for all applications; they may not choose between models on a case-by-case basis. States will need to indicate their assessment or determination decision to CMS in a State Plan Amendment, as well as in the Memorandum of Agreement it signs with the Federally-Facilitated Marketplace.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93731

Yes. In an assessment model, where an applicant is assessed eligible by the Federally-Facilitated Marketplace and later found to be ineligible by the state Medicaid agency, the state must transfer the account to the Federally-Facilitated Marketplace. Once received, the state Medicaid determination will be accepted and the account will be assessed by the Federally-Facilitated Marketplace for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits/Cost Sharing Reductions.

For the determination model, as discussed in section 435.1200(c), as governed by the agreement signed between the Medicaid agency and the Federally-Facilitated Marketplace, the Federally-Facilitated Marketplace determines eligibility for individuals applying to the Federally-Facilitated Marketplace for Medicaid/CHIP based on MAGI, and the state Medicaid or CHIP agency agrees to accept eligibility findings made by the Federally-Facilitated Marketplace.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93736

For individuals assessed eligible for Medicaid/CHIP by the Federally-Facilitated Marketplace, their account will be transferred to the state Medicaid/CHIP agency for a final determination. Once enrolled in Medicaid/CHIP, regardless of where the initial application was submitted, all updates, redeterminations and renewals are handled by the enrolling entity (e.g., the state Medicaid/CHIP agency). No further coordination would be needed with the Federally-Facilitated Marketplace except when an individual is found ineligible for Medicaid or CHIP during the redetermination process. In this case, the state agency would transfer the individual's account to the Federally-Facilitated Marketplace to be assessed for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits /Cost Sharing Reductions. The Federally-Facilitated Marketplace will not handle redeterminations or renewals for Medicaid/CHIP and will refer individuals to the appropriate site in the state as appropriate.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93741

No. There will not be integration of the Federally-Facilitated Marketplace and states' client registries. Instead, the Federally-Facilitated Marketplace will both verify current Medicaid/CHIP enrollment as part of the Federally-Facilitated Marketplace "applicant" application, and will also conduct quarterly checks of the Medicaid/CHIP enrollment files to determine any overlap with Federally-Facilitated Marketplace enrollment logs.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93746