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
Can a state submit a state plan amendment (SPA) to implement section 4106 of the Affordable Care Act at any time?
Yes, a state may submit a SPA at any time. The one percentage point increase in federal medical assistance percentage (FMAP) per the requirements outlined in section 4106 of the Affordable Care Act does not have an end date.
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FAQ ID:91511
SHARE URLUnder CMS 2370-F, may states continue to use discounted reimbursement rates for out-of-state or out-of-network eligible primary care providers, which may be less than the Medicare rate, for calendar years (CYs) 2013 and 2014?
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
SHARE URLMay states delegate the self-attestation process to their contracted managed care plans under CMS 2370-F rule?
Yes. A state may elect to delegate the self-attestation process to its contracting health plans under the following circumstances:
- 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.
- 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.
- 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.
- Such delegation is included in the contract amendment that is otherwise being filed to implement this provision.
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FAQ ID:91456
SHARE URLUnder the CMS 2370-F rule, are managed care organizations (MCOs) permitted to include amounts sufficient to account for the payment differential on expected utilization while still holding the sub-capitated primary care physicians at risk for some level of increase in utilization due to the higher rates? Or must MCOs remove the risk to primary care physicians for utilization to ensure that these physicians receive the increased amount for actual experience?
The purpose of section 1202 of the Affordable Care Act and the final rule is to ensure access to and utilization of beneficial primary care services. Towards that goal, eligible primary care physicians must receive the full benefit of the enhanced payment at the Medicare rate for eligible services rendered. If a Medicaid managed care health plan retains sub-capitation arrangements, the health plan would be obligated to provide additional payments to providers to ensure that every unit of primary care services provided is reimbursed at the Medicare rate.
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FAQ ID:91461
SHARE URLWill retroactive provider payments by health plans - necessitated by the State's retroactive payment of the higher rates to health plans - be subject to timely claims filing requirements in 42 CFR 447.46? If so, may states impose liquidated damages or other penalties on health plans for violating those requirements?
Any retroactive payments made to providers in order to ensure that eligible providers receive the applicable Medicare rate for eligible services will not be considered claims subject to the requirements in 42 CFR 447.46.
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FAQ ID:91411
SHARE URLCan managed care plans under contract with a state use their own definitions of primary care providers and services for purposes of complying with CMS 2370-F rule?
While we recognize that health plans may have unique definitions of primary care providers and services, the availability of the increased Federal Medical Assistance Percentage (FMAP) is limited to the scope of eligible primary care providers and primary care services as defined in statute and implemented by this rule.
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FAQ ID:91416
SHARE URLWhen will the Centers for Medicare & Medicaid Services (CMS) provide standardized contract language reflecting the requirements of this provision as mentioned during the All-State Call on November 8th?
CMS will be working collaboratively with the National Association of Medicaid Directors (NAMD) to develop the contract elements necessary to reflect the requirements of this rule. In recognition of the State Medicaid Agency's role in the contracting practice, CMS will describe the suggested content areas rather than issue standardized contractual language. These elements will be described in further detail in a future (Question and Answer) Q&A document.
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FAQ ID:91421
SHARE URLHow will states with Medicaid managed care programs comply with the requirement to report provider participation levels specified in 42 CFR 447.400(d)(1)?
At this time, the Center for Medicare & Medicaid Services (CMS) is not defining the form of information required under 42 CFR 447.400(d)(1), but we do suggest that states with Medicaid managed care programs conduct a baseline assessment of primary care access before the provision goes into effect. This baseline assessment will ensure that Congress, CMS, and researchers have comparative data to evaluate this provision.
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FAQ ID:91426
SHARE URLMany State demonstrations require that a transition plan to 2014 be submitted by a specified date, in many cases by July 1, 2012. Will CMS provide guidance and technical assistance before then? What specifically is required to be included in the transition plan?
CMS plans to provide technical assistance on transition plans to States through the State Operations and Technical Assistance Team (SOTA) calls and through other calls with the State. We will also be providing additional guidance about the information that should be included in the transition plans. We will consider the transition plans that need to be submitted by the due date as living documents that are open to revision, and will continue to work with States to ensure a seamless transition in 2014 for beneficiaries and States.
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FAQ ID:93021
SHARE URLHow should states account for the cost of the Health Insurance Providers Fee in their actuarially sound capitation rates?
States and their actuaries have flexibility in incorporating the Health Insurance Providers Fee into the state's managed care capitation rates. This fee is not unlike other taxes and fees that actuaries regularly reflect in developing capitation rates as part of the nonbenefit portion of the rate. CMS believes that the Health Insurance Providers Fee is therefore a reasonable business cost to health plans that is appropriate for consideration as part of the non-benefit component of the rate, just as are other taxes and fees.
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FAQ ID:91126
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