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
Our understanding of the CMS 2370-F rule is that advanced practice clinicians are eligible for the increased payment as long as they are working under the personal supervision of an eligible physician; eligible meaning the supervising physician is also eligible for the increased payment.
The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.
Supplemental Links:
FAQ ID:92106
SHARE URLThe requirements under 42 CFR 438.804 specify that the states submit two methodologies to the Centers for Medicare & Medicaid Services (CMS) for review and approval to implement the CMS 2370-F rule. How does approval of these methodologies impact the approval process for managed care contracts and rate packages for 2013?
Implementing regulations at 42 CFR 438.804 require states to submit to CMS a methodology for calculating the July 1, 2009, baseline rate for eligible primary care services and a methodology for calculating the rate differential eligible for 100 percent of Federal Financial Participation (FFP) by March 31, 2013. Further, 42 CFR 438.6 (c)(5)(vi) establishes Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PHIP) or Prepaid Ambulatory Health Plan (PAHP) contract requirements to comply with this provision. It is CMS's expectation that as soon as practicable after the State submits the required methodologies in 42 CFR 438.804 and receives CMS approval, the State will:
- Submit revised actuarial certification documents reflecting the Medicare rate for eligible primary care services in their MCO, PIHP or PAHP capitation rates; and
- Submit amendment(s) to this contract to ensure compliance with 42 CFR 438.6 (c)(5)(vi).
After CMS approval of the revised contract and rates, the MCO, PIHP or PAHP must direct the full amount of the enhanced payment to the eligible provider to reflect the enhanced payment effective January 1, 2013. Federal financial participation (FFP) is available at a rate of 100 percent for the portion of capitation rates attributable to these enhanced payments; however, receipt of the enhanced FFP is contingent upon the state's successful completion of this process.
Supplemental Links:
FAQ ID:91266
SHARE URLUnder section 4106 of the Affordable Care Act, is there a modifier to assist providers, payers and states in identifying preventive services?
The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
Supplemental Links:
FAQ ID:91991
SHARE URLUnder section 4106 of the Affordable Care Act, if the preventive service is bundled with other services, and the bundled service includes more than one preventive service, may the state allocate the bundled payment among the included services and claim the enhanced match for each of the preventive services? For example, in an annual exam, the physician provides both obesity counseling and alcohol misuse counseling. Can the state submit a claim for both the obesity counseling and the alcohol counseling?
It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.
Supplemental Links:
FAQ ID:91996
SHARE URLUnder section 4106 of the Affordable Care Act, are states required to follow only the summary of recommendations, or other information in the recommendation statement such as frequency? If the latter, reviewing potentially a ten-year claims history (e.g. for a colonoscopy) will be extremely burdensome.
Provided that the services are medically necessary, states are required to follow only the summary of recommendations for the services that have a rating of A or B from the United States Preventive Services Task Force (USPSTF). It is up to the state to have a financial monitoring procedure to ensure proper claiming for federal match.
Supplemental Links:
FAQ ID:92006
SHARE URLUnder section 4106 of the Affordable Care Act, for breast screenings, may the state claim the interpretation of the x-ray for the one percentage point federal medical assistance percentage (FMAP) increase, or can only the x-ray itself be claimed?
The state may claim the 1% FMAP increase on both the professional component (interpretation of the x-ray) and the technical component (the actual taking of the x-ray).
Supplemental Links:
FAQ ID:92011
SHARE URLUnder section 4106 of the Affordable Care Act, what information is being required for the CMS-64 reporting requirement to claim the increased federal medical assistance percentage (FMAP) for managed care expenditures?
States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all United States Preventive Services Task Force (USPSTF) grade A and B preventive services and approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP), and their administration, without cost-sharing. An approved state plan amendment is required for the lines to be enterable on the CMS-64 form. As with all other services claimed on the CMS-64, the amounts reported on and its attachments must be actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. The CMS-64 report form has been modified to allow for reporting of a state's managed care expenditures separate from the state's reporting of fee-for-service (FFS) expenditures. The total expenditures associated with services referenced in section 4106 would be reported on the requisite lines for managed care (line 18A4, 18B1d or 18B2d) and for FFS (line 34A).
Supplemental Links:
FAQ ID:92021
SHARE URLWhat federal matching rate will apply for services for which a higher payment is made under section 1202 of the Affordable Care Act, if the services also qualify for a higher federal medical assistance percentage (FMAP) under the provisions of section 4106 of the Affordable Care Act?
States that elect to cover all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and vaccine administration, without cost-sharing and who receive a SPA approval for such services shall receive the one percentage point FMAP increase per section 4106. Some of these services may also qualify as primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services, the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular FMAP rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act were followed.
Supplemental Links:
FAQ ID:92031
SHARE URLUnder section 4106 of the Affordable Care Act, what diagnosis codes must be billed in order to claim the 1% federal medical assistance percentage (FMAP) increase (the United States Preventive Services Task Force (USPSTF) A and B does provide a list of codes - should we limit our review to them)?Are we required to make sure these services are for preventive screening and not for disease diagnosis? For example, anemia testing in pregnant women can be part of routine prenatal care, and a provider may order it later in a pregnancy if the woman complains of fatigue.The same service may be screening or diagnostic. How does CMS want states to differentiate? For example, we will pay a lab claim for a lipid panel. Having to match with the International Classification of Diseases (ICD) code (e.g. the presence or absence of hyperlipidemia) is burdensome, and ICD code may reflect either existing condition or purpose of ruling out that condition.The Medicaid billing codes associated with the eligible preventive services verify that a service was provided; they do not differentiate between services that are provided for preventive reasons and services that are provided for diagnosis maintenance. We would like CMS guidance on how this differentiation is to be identified.
As long as the state covers all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing, such services will be eligible for the one percentage point federal medical assistance percentage (FMAP) increase. State Medicaid agencies should work with, and communicate to, providers concerning state-specific systems and the appropriate codes to use.
Supplemental Links:
FAQ ID:92041
SHARE URLUnder section 4106 of the Affordable Care Act, if our program expects that a particular screening be done as part of an Evaluation and Management (E&M) coded visit, how does that relate to CMS coverage expectations? Counseling and verbal screening are often incorporated into an E&M visit. Does CMS require that states have distinct coding and reimbursement rates for physician time spent: 1) measuring blood pressure 2) counseling about alcohol misuse 3) making a referral for BRCA screening 4) discussing breast cancer chemoprevention 5) counseling on breastfeeding 6) prescribing oral fluoride 7) screening for depression 8) screening for intimate partner violence 9) screening for obesity 10) counseling to prevent skin cancer 11) counseling on tobacco cessation
We recognize that an E&M service may include a United States Preventive Services Task Force (USPSTF) grade A or B service (for example, blood pressure screening). To receive the one percentage point federal medical assistance percentage (FMAP) increase, states are required to cover in their standard Medicaid benefit package all USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing. It is up to the state to determine how the billing should occur. In the examples mentioned above, if you consider these USPSTF grade A or B recommended services to be an integral part of the office visit, and they will not be billed separately, the state may continue that billing practice. The state may claim the one percentage point FMAP increase on the office visit only if the primary purpose of the office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. The state should work with providers and payers to ensure that Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services are followed. We wish to confirm that a state must be able to document expenditures claimed on the CMS-64 and we believe the best way to accomplish this is through the billing process.
Supplemental Links:
FAQ ID:92046
SHARE URL
Results per page