Frequently Asked Questions

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.

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92156

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

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

Amounts reimbursed by Medicaid are pre-rebate, not net of rebates.

FAQ ID:92001

"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

States are required to submit their utilization data to CMS within 60 days of the end of the rebate period.

FAQ ID:92026

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

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

In general, all states cover all drugs (that meet the statutory definition of a covered outpatient drug per section 1927 of the Social Security Act (the Act)) of every manufacturer that participates in the Medicaid Drug Rebate Program (MDRP). However, section 1927(d)(2) of the Act does list several categories of drugs that states may, at their option, exclude or restrict from coverage under the MDRP. These categories include things like non-prescription drugs, drugs used for cosmetic purposes, etc. Therefore, while most states cover the same subset of drugs, there is some flexibility afforded to the states which can result in coverage differences from one state to the next.

FAQ ID:92066

State-only program utilization (e.g. ADAP) should not be included in the Federal State Medicaid Drug Rebate Program.

FAQ ID:92071