Frequently Asked Questions

Annually, CMS will request a list of covered durable medical equipment HCPCS codes from the Medicare Pricing, Data Analysis and Coding Contractor. Once the list is received, CMS will distribute the list through the CMS Regional Office Associate Regional Administrator.

FAQ ID:93671

To address claims run-out and ensure compliance with the FFP limit, we recommend states with these concerns conduct interim FFP limit demonstrations for DME no later than three months after the end of the calendar year for the previous calendar year (that is, January 1-December 31). The interim DME FFP limit demonstration will be due by March 31 of each calendar year and will contain data for the period of January 1 to December 31 of the preceding year. The final demonstration would be due one year later on March 31 and include all claims received during the run-out period dates of service within the interim demonstration period. The interim demonstration process should provide states with an understanding of potential violations of the FFP to make any necessary budgeting and rate changes. This method is being used to allow provide for a reasonable claims run out period as allowed under 42 CFR 424.44, which states that claims must be filed no later than one calendar year after the date of service.

FAQ ID:93676

OMB Circular A-87requires costs associated with building shared state-based Information Technology (IT) systems that support multiple health and human service programs be allocated across all benefitting programs in proportion to their use of the system. The OMB A-87 Exception revised this approach by allowing human service programs (e.g. SNAP, TANF, LIHEAP, etc.) and others to utilize a wide range of IT components, needed by Medicaid but also of use to these other programs, at no additional cost except for interfaces or other uniquely required services specific to those programs. The A-87 Exception applies only to design, development, and implementation. Maintenance and operations work should continue to be allocated in accordance with the A-87 Circular. OMB Circular A-87  – Cost Principles for State, Local, and Indian Tribal Governments, has been Relocated to 2 CFR, Part 225 .

FAQ ID:93611

On July 20, 2015, the U.S. Department of Health and Human Services and the U.S. Department of Agriculture announced a three-year extension of the Exception to the OMB A-87 cost allocation requirements from December 31, 2015 to December 31, 2018. We are currently making plans for the OMB A-87 exception to end.

FAQ ID:93616

States will need to incur costs for goods and services furnished no later than December 31, 2018 to make use of this Exception. Therefore, if work is completed by December 31, 2018, it can be funded under the OMB A-87 Exception and states should follow typical invoicing and claiming processes. However, if an amount has been obligated by December 31, 2018, but the good or service is not furnished by that date, then such expenditure must be cost allocated by program in proportion to their use of the system in accordance with OMB A-87.

FAQ ID:93621

For FFY2019 annual APDs and budget tables, including the Medicaid Detailed Budget Table (MDBT), must be completed as follows:

• For Q1 FFY2019, states can allocate costs in accordance with the OMB A-87 Exception
• For Q2-Q$ FFY2019, and all APDs going forward, states should allocate costs as required under the OMB A-87 Circular

If a state has already submitted their annual APDs without providing separate budgets they will need to complete an APDU with a revised MDBT and cost allocation plan. The update should address how cost allocation will be done prior to, and after, December 31, 2018. Budget tables should be completed as described above.

The Data and Systems Group (DSG) that approves APDs does not approve cost allocation methodology. States working to develop their new methodologies should send operational cost allocation plans to Cost Allocation Services  and the regional office fiscal staff for all benefiting programs.

FAQ ID:93626

Federal financial participation (FFP) limit demonstrations for durable medical equipment (DME) will be due 3 months after the end of the calendar year for the previous calendar year (i.e., January 1-December 31). The first DME FFP limit demonstration will be due by March 31, 2019 and will contain data for the period of January 1, 2018 to December 31, 2018. This reporting period was selected to coincide with the effective date of the statute (January 1, 2018).

FAQ ID:93486

The statute does not compel states to set their payment rates for durable medical equipment (DME) at specific Medicare rates for each specific item. Instead, the statute applies a limit on available federal financial participation (FFP) for state aggregate expenditures. States have the flexibility to set their own rates for DME in the Medicaid program. If a state decides to set their Medicaid payment rates at or below Medicare rates in the state plan, the state should be specific about the fee schedule the state will use and be prepared to demonstrate that their rates do not exceed the amount Medicare would have paid in the aggregate, in order to avoid the annual FFP limit demonstration of aggregate expenditures. For the demonstration, the Centers for Medicare & Medicaid Services (CMS) will be using state-specific Medicare payment rates. With this limit of available FFP for the aggregate amount of DME, CMS will use either the Medicare rates specific to an area of the state for the services rendered in those areas, or the lowest of a state’s Medicare rates for comparison to the aggregate limit of FFP.

FAQ ID:93491

States are free to establish higher rates for particular items of DME if they determine that higher rates are needed under the Medicaid state plans. If, however, the aggregate expenditures would exceed the Medicare rates in the aggregate, federal financial participation (FFP) would be limited. States that determine that payments above Medicare aggregate totals are necessary may use state-funds to obtain particular items of DME. The statute specifically describes an aggregate limit on state expenditures only for purposes of paying FFP. Therefore, a state may pay more than the Medicare rate for a particular item of DME, and as long as the aggregate amount for all DME is not exceeded, no FFP is at risk. Even if the aggregate amount is exceeded, there is only a limit on FFP, and there is no limit on the use of state funds used on DME items.

FAQ ID:93496

The Centers for Medicare & Medicaid Services cannot delay implementation of the statute. Congress took specific action to move the effective date up to January 1, 2018, and we are unable to amend the effective date.

FAQ ID:93501