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
Are fluoride treatments (also known as fluoride varnishes) eligible for the one percentage point increase in federal medical assistance percentage (FMAP) under section 4106 of the Affordable Care Act?
No, fluoride varnish is not eligible for the one percentage point FMAP increase. In the future, if the United States Preventive Services Task Force (USPSTF) adds fluoride varnish to the A or B recommended preventive services, states will be required to cover the fluoride varnish with no cost-sharing. Per State Medical Director (SMD) letter #13-002, states should provide an assurance in the state plan indicating they have a method to ensure that, as changes are made to the USPSTF and the Advisory Committee on Immunization Practices (ACIP) recommendations, they will update their coverage and billing codes to comply with those revisions. As long as this assurance is in the state plan, states are not required to submit a state plan amendment each time the USPSTF or ACIP makes changes to their recommendations.
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FAQ ID:91536
SHARE URLUnder section 4106 of the Affordable Care Act, the list of United States Preventive Services Task Force (USPSTF) preventive services describes services as being available for persons based on their sex and age range. For example: Abdominal aortic aneurysm screening (men): The USPSTF recommends one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked. Are states required to follow the USPSTF grade A and B recommendations on age, gender and smoking status in order to claim the one percentage point federal medical assistance percentage (FMAP) increase for a particular service?Since some recommendations have start and stop ages, are states required to perform age edits on each service for each individual?
States may only claim the one percentage point FMAP increase on services that adhere to the USPSTF grade A and B recommendations on age, gender, periodicity and other criteria as indicated in the summary of recommendations. For instances where the USPSTF grade A and B recommendations have expanded age, gender or periodicity levels due to clinical considerations, practitioners should document in the patient's medical record the necessity for exceeding the grade A and B recommendations, and states may claim the one percentage point FMAP increase. When billing for these services, payers may want to use modifier 33 to identify services that meet the criteria for the USPSTF grade A and B recommendations. Pursuant to page 2 of State Medical Director (SMD) letter #13-002, states should have a financial monitoring procedure in place to ensure proper claiming for federal match.
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FAQ ID:91541
SHARE URLIs there a state plan amendment (SPA) pre-print the states can use to comply with section 4106 of the Affordable Care Act or is CMS planning to issue one?
For states seeking the one percentage point federal medical assistance percentage (FMAP) increase, the SPA requirements are indicated on pages 3 and 4 of the State Medicaid Director (SMD) letter #13-002. CMS will not provide a state plan template on section 4106 of the Affordable Care Act. However, staff are available to provide technical assistance prior to your SPA submission.
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FAQ ID:91546
SHARE URLUnder section 4106 of the Affordable Care Act, if a state elects to cover preventive services to be eligible for the one percentage point federal medical assistance percentage (FMAP) increase, must we cover all of the United States Preventive Services Task Force (USPSTF) A and B preventive services or can we cover just a few?
All USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase.
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FAQ ID:91551
SHARE URLWhile section 4106 of the Affordable Care Act authorizes a 1% federal medical assistance percentage (FMAP) increase for tobacco cessation services for pregnant women, the State Medical Director (SMD) letter does not address this proposed increase. Please clarify if this qualifies for the 1% FMAP increase.
The United States Preventive Services Task Force (USPSTF) recommendation for tobacco use counseling for pregnant women is grade A. Therefore, tobacco use counseling for pregnant women shall receive the one percentage point increase in FMAP. In addition, section 4106 of the Affordable Care Act states "items and services described in subsection (a)(4)(D)". Therefore, the one percentage point increase pertains to the comprehensive tobacco cessation services for pregnant women that are described in section 4107 of the Affordable Care Act.
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FAQ ID:91556
SHARE URLSection 4106 of the Affordable Care Act states that "any medical or remedial services [designed] for the "maximum reduction" of physical or mental disability and restoration of an individual to the best possible functional level" was also authorized to receive 1% federal medical assistance percentage (FMAP); however, the State Medical Director (SMD) letter does not address this provision. Please clarify if this is included, if yes, please provide information as to how this should be captured in claims data.
The statute amended section 1905(b) of the Social Security Act (Act) only to provide for the higher federal matching rate for services and vaccines described in subparagraphs (A) and (B) of section 1905(a)(13) of the Act . These subparagraphs are limited to "clinical preventive services assigned a grade of A or B by the United States Preventive Services Task Force (USPSTF), adult vaccinations, and comprehensive tobacco cessation for pregnant women. This is a subset of the services described in section 1905(a)(13) of the Act.
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FAQ ID:91561
SHARE URLFor Medicaid eligible children, the state does not reimburse for the immunizations due to the Vaccines for Children (VFC) program. The state only reimburses for the vaccine administration code. Are the administrative codes for children's immunizations eligible for the preventive services federal medical assistance percentage (FMAP) increase under section 4106 of the Affordable Care Act?Can the fee for administration of the adult vaccines receive the one percentage point increase in FMAP?
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
SHARE URLIn some of the recommendations, a drug is mentioned, for example, "aspirin to prevent cardiovascular disease." Does the 1% federal medical assistance percentage (FMAP) increase apply to the drug under section 4106 of the Affordable Care Act?
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
SHARE URLUnder section 4106 of the Affordable Care Act, do we receive the 1% federal medical assistance percentage (FMAP) increase on only those services identified by the United States Preventive Services Task Force (USPSTF) A and B?
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
SHARE URLIn the law it is found under adult preventive services. I noticed that the items listed in the United States Preventive Task Force (USPSTF) grade A and B services include screening for children. Does the 1% federal medical assistance percentage (FMAP) increase only apply to services provided to adults (beneficiaries ages 21 and older)?
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
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