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 oxygen and related equipment included in the durable medical equipment (DME) limit on federal financial participation (FFP) (e.g., concentrator and its contents, continuous positive airway pressure (CPAP) machines, etc.)?
Yes. To the extent that Medicare classifies such items as DME equipment and such items are covered by Medicare, they are included in the FFP limit in the statute. Oxygen supplies are included in the DME limit on FFP according the Medicare definition on DME.
FAQ ID:93581
SHARE URLCan states elect not to submit data to the Centers for Medicare & Medicaid Services (CMS) using the calculation tool and instead conduct their own analysis?
States have the flexibility to conduct their own analysis and use their own calculation tool to show compliance to the statute. CMS has received approval through the paperwork reduction act to have the calculation tool collection of information be used for ease of administration for states in their durable medical equipment federal financial participation limit demonstration reporting and analysis. CMS asks states not using the calculation tool to contact the resource mailbox: MedicaidDME@cms.hhs.gov.
FAQ ID:93586
SHARE URLConsidering claims volume is a critical component of the aggregate Medicare expenditure limit, what is the relationship between the Medicaid claims volume and Medicare claims volume for the same durable medical equipment item? Will the claims volume under Medicare be geographically segregated?
For purposes of the federal financial participation (FFP) limit, Medicare claims volume will not be considered in the demonstration of the limit. Only Medicaid claims volume is relevant for the calculation of the FFP limit.
FAQ ID:93591
SHARE URLWill states receive detailed reconciliation data returned to them after submitting their durable medical equipment (DME) federal financial participation limit demonstration?
The Centers for Medicare & Medicaid Services (CMS) will analyze state data provided to CMS and return the detailed information comparing the data sent from the state to the lowest and average Medicare rates for the relevant DME in the state on the aggregate. CMS will work with states during 2018 to assist with reporting necessary information under the new statute, and will run data reports for states before the end of the year if requested. A state that wishes this review should contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.
FAQ ID:93596
SHARE URLShould states set both a purchase and rental rate for capped rental items on the report since Medicaid pays purchase only for some of the Medicare capped rental items due to market demands?
States are not required to change how they pay for items because of the statute. If a Medicaid program only purchases Medicare capped rental items, then that is the payment and utilization we will compare to Medicare’s rates in determining the aggregate expenditures. States are not obligated to alter their coverage of durable medical equipment due to the statute.
FAQ ID:93601
SHARE URLIf Medicare changes a rate mid-year, how will the reporting requirement account for that change? Or how will the state be informed of the change?
For the aggregate demonstration of Medicaid expenditures, we intend to use the Medicare rates released for services on or after January 1 of each year. We would suggest that states setting their rates according to Medicare rates in the state plan would follow a similar practice. States are, of course, welcome to use the quarterly updates of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) if that’s their intention, but we are not requiring those rate updates beyond the January 1 DMEPOS update.
FAQ ID:93606
SHARE URLHow can a state contact the Centers for Medicare & Medicaid Services (CMS) for help with the federal financial participation (FFP) Limit for state expenditures for durable medical equipment (DME)? Where can a state submit statements and supporting evidence that the states are already in compliance with this DME limit on FFP based on the state using Medicare rates?
For technical assistance with the implementation efforts and assistance with determining if current state practices are below the FFP limit, please contact the Medicaid DME mailbox: MedicaidDME@cms.hhs.gov.
FAQ ID:93476
SHARE URLWhere can states find a list of the Medicare competitive bidding areas (CBAs), including zip codes and areas of the state, and how does a state find out if it has CBAs?
States may review Medicare’s CBAs through the following website for the most up-to-date information: www.dmecompetitivebid.com. In the alternative, the Center for Medicaid and CHIP Services (CMCS) has a list of states and CBAs by state that is available upon request. We will monitor the lists and update them with any necessary Medicare changes. As of January 1, 2018, the following states and territories do not have CBAs: Alaska, Maine, Vermont, North Dakota, South Dakota, Montana, Wyoming, and all of the US territories.
FAQ ID:93481
SHARE URLPlease clarify that state flexibility to reimburse in the aggregate extends to reimbursement rates for I/T/U pharmacies and FSS drugs, and that states can establish rates that are based on a variety of data sources, which may include FSS prices, national and State price surveys, AMP data, and other price benchmarks.
The new AAC requirements were designed to more accurately reflect the pharmacy providers' actual prices paid to acquire drugs and the professional services required to fill a prescription. We agree that each state is able to establish rates that satisfy (or are consistent with) AAC and may be based on a variety of data sources, which may include FSS prices, and other pricing benchmarks.
FAQ ID:95111
SHARE URLIf a state can prove that they are under the aggregate limits of AAC and PDF and have strong participation by pharmacies, are they required to adopt the AAC and PDF reimbursement methodology at the individual claim level?
All states are required to adopt the AAC and professional dispensing fee methodology; however, it is not required to be adopted at the individual claim level, but in the aggregate. In accordance with the regulatory requirements at 42 CFR 447.512(b), the state is responsible for establishing a payment methodology, that must not exceed, in the aggregate, payment levels that the agency has determined by applying the lower of the AAC plus a professional dispensing fee or the providers' usual and customary charges to the general public. In conjunction with this the state is also responsible to ensure that pharmacy reimbursement is consistent
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94691
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