Frequently Asked Questions

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

While section 4106 of the Affordable Care Act states that USPSTF grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration must be covered to secure the one percentage point FMAP increase, it is incumbent upon state Medicaid agencies to continue to work with, and communicate to, providers concerning state-specific systems and appropriate codes. The information provided by the American Medical Association in the below link (the CPT Code Pocket Guide: Preventive services with cost-sharing waived) can be used as a starting point in creating a cross-walk from the USPSTF and ACIP recommended codes, but it is not all-inclusive.

In addition, the October 2012 State Health Official (SHO) letter, gave the below web site address for HCPCS codes effective for service dates on or after January 1, 2012, and contacts within CMS for questions regarding HCPCS codes.

http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html 

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FAQ ID:91686

CMS recently received information from the American Board of Medical Specialties attesting that the American Board of Allergy and Immunology (ABAI) is an ABMS-recognized sub-discipline of the American Board of Pediatrics and the American Board of Internal Medicine.

Specifically, the ABAI is a conjoint board of the American Board of Pediatrics (ABP) and the American Board of Internal medicine (ABIM). All physicians certified by the Board of Allergy and Immunology must first be board certified by either ABP or ABAI. Medical specialists certified by the Allergy and Immunology Board remain subspecialists of Internal Medicine and Pediatrics. However, it is possible that some holders of a certificate from ABAI will not have a current certificate in Internal Medicine or Pediatrics because some diplomats of the ABP and ABIM who hold subspecialty certificates are not required to maintain their primary certificates. The ABMS was concerned that these diplomats might be excluded from eligibility for higher payment under a strict interpretation of the rule even though they do act as their patients' primary care provider in many cases and urged that CMS formally recognize that diplomats of ABAI are, in fact subspecialists in Internal Medicine and Pediatrics and eligible for higher payment up to the Medicare rate.

Based on this information, CMS agrees that allergists are eligible for higher payment under the rule.

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FAQ ID:91486

While there is no deadline given in the provision for states to create public awareness campaigns to inform Medicaid beneficiaries of the preventive services covered in their state, CMS looks forward to partnering with states to develop innovative approaches. CMS is required to prepare a periodic Report to Congress including "summaries of the states' efforts to increase awareness of coverage of obesity-related services," and the next report will be submitted by January 1, 2014. As such, CMS is gathering information about states' efforts to inform the 2014 report. States may email MedicaidCHIPPrevention@cms.hhs.gov to submit information about preventive and obesity-related services public awareness efforts in their communities.

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FAQ ID:91491

Technical assistance questions, as well as information about state Medicaid prevention efforts, can be directed to: MedicaidCHIPPrevention@cms.hhs.gov and/or Deirdra Stockmann, 410-786-2433.

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FAQ ID:91501

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