Frequently Asked Questions

Generally, information from the Federal data services hub will only be sent in direct response to a call from the requesting entity. However, in the case of verifications conducted by DHS, there can be up to three steps to a verification, the second and third of which will not be in real time. If the step 1 query fails, the Federal data services hub will automatically invoke step 2, and the response may take up to several days. If step 2 fails, the Federal data services hub will notify the requesting entity which will need to submit additional documentation from the applicant for step 3. The step 3 response can take weeks. During this time, the Federal data services hub will regularly poll DHS to see if the response has come back.

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FAQ ID:93316

The statute and regulations require that states provide individuals several channels through which they can apply for Medicaid and CHIP coverage - by mail, in person, on line and over the telephone. Following are some guiding principles for administering telephonic applications based on successful strategies many states have in place today.

1. Accepting a Telephonic Application - States may develop their own processes for accepting and adjudicating telephonic applications. The process for accepting applications by phone must be designed to gather data into a sufficient format that will be accessible for account transfer to the appropriate insurance affordability program. For example, a customer service representative could verbally communicate application questions to the applicant, while electronically filling out the online version of the single streamlined application.
2. Voice Signatures - All applications must be signed (under penalty of perjury) in order to complete an eligibility determination. In the case of telephonic applications, states must have a process in place to assist individuals in applying by phone and be able to accept telephonically recorded signatures at the time of application submission. If applicable, states can maintain their current practices of audio recording and accepting voice signatures as required for identity proofing.
3. Records and Storage - Upon request, states must be able to provide individuals with a record of their completed application, including all information used to make the eligibility determination. As such, CMS recommends that states record all telephonic applications. This may be accomplished by taping the complete application transaction as an audio file, or by producing a written transcript of the application transaction, among other options. The length of storage of these records should comply with current regulations on application storage.
4. Confirmations and Receipts - States should provide a confirmation receipt documenting the telephonic application to the applicant. Such confirmation should be provided upon submission of the application or at any time the applicant wishes to end the customer representative interaction. Confirmation receipts can be delivered via electronic or paper mail (based on the applicant's preference). Confirmation receipts must include key information for applicants, including but not limited to the application summary, the eligibility determination summary page, a copy of the attestations/rights and responsibilities and the submission date of the signed application.

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FAQ ID:92156

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

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

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

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:91446

Yes. A state may elect to delegate the self-attestation process to its contracting health plans under the following circumstances:

1. Each managed care plan has signed documentation on file (provider contract or credentialing application) from the eligible provider attesting to the fact that he or she has a covered specialty or subspecialty designation. This addresses step one of the two-step self-attestation process specified in the rule.
2. The managed care plan has verification of the provider’s appropriate board certification (as part of the credentialing and re-credentialing process). This addresses one option of the second step in the self-attestation process.
3. Should board certification in the eligible specialty not be able to be verified by the managed care plan, the eligible provider must provide a specific attestation to the managed care plan that 60 percent of their Medicaid claims for the prior year were for the Healthcare Common Procedure Coding System (HCPCS) codes specified in the regulation. This addresses a second option for the second step in the self-attestation process.
4.  Such delegation is included in the contract amendment that is otherwise being filed to implement this provision.

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FAQ ID:91456

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.

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.

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.

FAQ ID:91091