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
What if I encounter an account that does not appear to fit into any of a state's eligibility coverage groups?
Applicants that indicate they have a disability, need long-term care or are over age 65 are always referred to the Medicaid agency for a determination on a non-MAGI basis, regardless of income and household composition, since the FFM is evaluating eligibility for MAGI-based eligibility groups only. Additionally, applicants may always request a full Medicaid determination at the end of the application process. In assessment states, the Medicaid agency will do a final determination of eligibility for these applicants, whereas in determination states, the Medicaid agency just needs to follow up for a non-MAGI determination. The expanded flat file will contain a specific indicator showing if the applicant requested a full determination.
Supplemental Links:
FAQ ID:92136
SHARE URLPlease clarify that state flexibility to reimburse in the aggregate extends to reimbursement rates for I/T/U pharmacies and FSS drugs, and that states can establish rates that are based on a variety of data sources, which may include FSS prices, national and State price surveys, AMP data, and other price benchmarks.
The new AAC requirements were designed to more accurately reflect the pharmacy providers' actual prices paid to acquire drugs and the professional services required to fill a prescription. We agree that each state is able to establish rates that satisfy (or are consistent with) AAC and may be based on a variety of data sources, which may include FSS prices, and other pricing benchmarks.
FAQ ID:95111
SHARE URLCan states that pay for inpatient hospital services using Diagnosis Related Grous (DRGs), but historically used a cost-based UPL, continue to use the cost-based Upper Payment Limit (UPL) method?
Yes, states may use UPL methodologies that are different from their payment methodologies. For example, a state may pay for inpatient hospital services using a Medicaid APR-DRG methodology, but use a cost methodology to compute the Medicare upper payment limit for its UPL demonstration.
FAQ ID:92386
SHARE URLWhat is the difference between "Medicaid Amount Reimbursed" vs. "Non-Medicaid Amount Reimbursed" in the State Drug Utilization Data (SDUD)?
A Non-Medicaid Reimbursed amount is any amount paid on a claim by parties other than Medicaid (e.g., other federal coverage, co-pay, private insurance). If a state receives Federal Financial Participation (FFP) for any part of a claim for a Covered Outpatient Drug (COD), that portion of the claim is included in the Medicaid Reimbursed amount. If a state does not receive FFP for any part of a rebate-eligible claim, then the amount of the claim is included in the Non-Medicaid Reimbursed amount.
FAQ ID:91981
SHARE URLWhy Does the "Medicaid Amount Reimbursed" and the "Non-Medicaid Amount Reimbursed" not equal the "Total Amount Reimbursed" in the State Drug Utilization Data (SDUD)?
The sum of the “Medicaid Amount Reimbursed” and the “Non-Medicaid Amount Reimbursed” fields should generally equal the Total Amount Reimbursed on a National Drug Code (NDC) by NDC basis; however, these new fields were implemented beginning with the fourth quarter of 2007 and are optional for the states to report prior to that time. Therefore, for quarters earlier than fourth quarter 2007, there may be some large discrepancies between the Total Amount Reimbursed and the sum of the Medicaid Amount Reimbursed and the Non-Medicaid Amount Reimbursed because the Non-Medicaid Amount Reimbursed is often not present for those earlier quarters. Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.
FAQ ID:91986
SHARE URLIs the amount reimbursed by Medicaid net of rebates or pre-rebate in the State Drug Utilization Data (SDUD)?
Does the State Drug Utilization Data (SDUD) field "Units Reimbursed" represent the number of pills Medicaid paid for a drug that comes in a pill form?
"Units Reimbursed" are the number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state or, for MCO drugs, the number of units dispensed during the Quarter/Year. For more specific information, you may contact either the Drug Manufacturer or State via the contact lists.
FAQ ID:92016
SHARE URLWhen are states required to submit State Drug Utilization Data (SDUD) to the Centers for Medicare & Medicaid (CMS)?
States are required to submit their utilization data to CMS within 60 days of the end of the rebate period.
FAQ ID:92026
SHARE URLHow long does a state have to report State Drug Utilization Data (SDUD) that was not previously reported?
Per section 1927 of the Act, initial submissions of quarterly state utilization data are due to CMS within 60 days of the end of each rebate period. If a state fails to report utilization data in the quarter that it was dispensed, the state must submit initial utilization data for the most recently closed quarter as well as adjustments/corrections to any previously reported utilization data.
FAQ ID:92036
SHARE URLAre all states required to participate in the Medicaid Drug Rebate Program (MDRP)? If not, is there a listing published by Medicaid indicating who is not participating?
Drug coverage under Medicaid is an optional benefit for the states. However, if a state opts to cover prescription drugs in their Medicaid program, they must participate in the MDRP. As part of that participation in the MDRP, states are required to submit quarterly drug utilization data to CMS. All states and the District of Columbia currently participate in the MDRP; therefore, they all submit quarterly drug utilization data to CMS.
FAQ ID:92061
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