Frequently Asked Questions

Section 1905(a)(13)(B) of the Act is limited to adult vaccines, therefore, the following applies:

• Children age 18 and under: Vaccines are provided through the VCF program. Therefore, the one percentage point increase does not apply. For this age group, the vaccine administration fee is not eligible for the one percentage point FMAP increase.
• Individuals age 19 and 20: Vaccines are not available through the VCF program for this age group. This age group may receive the one percentage point increase in FMAP on both the vaccines and the vaccine administration fee.
• Adults ages 21 and older: Both the Advisory Committee on Immunization Practices (ACIP) recommended vaccines and the vaccine administration fee are eligible for the one percentage point increase in FMAP.

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FAQ ID:91566

No, the one percentage point FMAP increase does not pertain to prescribed drugs (including over-the-counter drugs prescribed by a healthcare professional) that are claimed on the "Prescribed Drugs" line of the CMS-64 form. However, the one percentage point FMAP increase applies to injectable drugs that receive a United States Preventive Services Task Force (USPSTF) grade A or B recommendation and are provided in a clinical setting for the primary purpose of prevention. Cost-sharing should be waived for such services.

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FAQ ID:91576

The one percentage point FMAP increase is available only for USPSTF Grade A and B services, comprehensive tobacco cessation services for pregnant women, Advisory Committee on Immunization Practices (ACIP) recommended vaccines for adults, and their administration.

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FAQ ID:91601

The one percentage point FMAP increase applies to the USPSTF grade A and B recommended services for the populations referenced in the recommendations.

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FAQ ID:91611

The newly eligible FMAP (described in section 1905(y)(1) of the Act) is 100 percent in calendar years 2014-2016, 95 percent in calendar year 2017, 94 percent in calendar year 2018, 93 percent in calendar year 2019, and 90 percent in calendar years 2020 and beyond.

For states who opt to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, for calendar years 2014-2016, the one percentage point increase for newly eligible individuals wouldn't apply, as the FMAP for that group is 100 percent.

Starting in 2017 and beyond, when the newly eligible FMAP goes to 95 percent and below, the one percentage point increase for the services mentioned in section 4106 of the Affordable Care Act would apply to the newly eligibles. Example: For 2017, newly eligibles would receive 95 percent FMAP. If the state opts to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, per the guidelines in State Medicaid Director Letter (SMDL) 13-002, the state would receive 96 percent FMAP on such services for the newly eligibles.

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FAQ ID:91621

Yes, that is correct. The one percentage point FMAP increase under section 4106 applies only to the FMAP set forth under section 1905(b) and section 1905(y) of the Act; it does not apply to FMAP rates under section 1903(a) of the Act. However, any family planning related service that also is recognized by section 4106 and matched at the state's regular FMAP is eligible to receive the one percentage point FMAP increase.

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FAQ ID:91636

If the state is meeting the requirements outlined in State Medical Director (SMD) letter #13-002, the state may receive the one percentage point FMAP increase on the Medicaid liability after coordination of benefits occurs.

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FAQ ID:91646

Clinical preventive services that receive an I or C recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover I or C recommended services. However, United States Preventive Task Force (USPSTF) grade I and C recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.

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FAQ ID:91661

Clinical preventive services that receive a D recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover D recommended services. However, United States Preventive Services Task Force (USPSTF) grade D recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.

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FAQ ID:91666

"Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment Final Rule" (CMS-2334-F), published in the Federal Register on 7/15/2013, conformed the regulatory definition of preventive services at § 440.130(c) with the statute relating to the issue of who can be providers of preventive services. Per the final rule, effective 1/1/2014, preventive services may be recommended by a physician or other licensed practitioner. Therefore, unlicensed practitioners will be able to furnish preventive services (including the services mentioned in section 4106), based on the recommendation of a physician or other licensed practitioner, according to the provider qualifications established by each respective state, within broad federal parameters. In order for states to receive the one percentage point federal medical assistance percentage (FMAP) increase for unlicensed practitioners, it is likely that a state plan amendment updating section (13)(c) of the state plan will be necessary. Please refer to the preventive service CMCS Informational Bulletin issued on November 27, 2013 for additional information regarding adding unlicensed practitioners to the preventive services section of the state plan.

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FAQ ID:91676