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
If a state is reusing an MMIS system or module already certified in another state do they need to go through certification review and decision?
CMS encourages states to reuse modular solutions as much as possible. If a state can reuse a modular solution from another state with minimal changes or customization, CMS will work with the state to streamline the certification process as much as possible to leverage knowledge of the reused solution. However, CMS will still require a certification decision for each state implementation of reused solutions to ensure compliance with federal regulations.
FAQ ID:94896
SHARE URLWhich of the checklist paths (MITA, Module, Custom) described in the MECT are best for a state implementing a services-type solution?
All the criteria in the checklists (MITA, MMIS or Custom) are the same. The difference between checklists is the criteria organization within the checklists. If the services solution is innovative, unique, or an unconventional approach, then the custom checklist approach might be appropriate. The RO will work with the state and vendors to decide which checklist set is best suited for the state's certification. Both service and traditional-type solutions need to meet all certification criteria to ensure compliance with federal regulations.
FAQ ID:94901
SHARE URLIf the state conducts a staged rollout for implementing new MMIS Medicaid modules, will CMS pay for the overlapping costs?
Yes, CMS will support the costs for this kind of MMIS transition. We encourage states to ensure that both the current vendor's and new solutions provider's contracts account for this transition period and address a prorating of cost during this time. States should minimize the costs of transition by performing due diligence on the anticipated spending. The legacy system provider should be compensated for its role in ensuring a smooth transition, with a ramp-down of other operational costs. The new solutions provider should have deliverables in its contract that speak to the soft launch or phased launch approach, with an uptick in operational costs as the transition progresses.
FAQ ID:94906
SHARE URLWhat security and privacy documents are state Medicaid agencies required to have for their MMIS?
State Medicaid agencies are required to have MMIS System Security Plan and Privacy Impact Assessment documents. State Medicaid agencies must perform regular routine security and privacy risk assessments to ensure the protection and safeguard of beneficiary data that is consistent with Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules. Please refer to the MECT for more details: https://www.medicaid.gov/medicaid/data-and-systems/mect/index.html
FAQ ID:94911
SHARE URLCan the Systems Integrator (SI) be awarded contracts for development of modular components within the MMIS project?
Yes. While CMS envisions a discrete role for the System Integrator (SI) in each state, with specific focus on ensuring the integrity and interoperability of the Medicaid IT architecture and coherence of the various modules incorporated into the Medicaid system complex, it is permissible for an SI to provide modules as part of the overall solution. The target outcome for the SI in support of the state should be to foster best-in-breed solutions for Medicaid business requirements, with the SI responsible for the successful integration of the chosen solutions and infrastructure into a seamless functional system. The SI must ensure that all modules have open APIs and remain loosely coupled. More information on the SI role can be found in Section 1.7 of the Medicaid Enterprise Certification Life Cycle, part 01 of the MECT. States are encouraged to use an acquisition approach that limits the potential for conflict of interest an SI may have in choosing the modular solutions to be incorporated into the system. As described above, the goal is to avoid lock-in to a single vendor or an otherwise closed set of solutions.
FAQ ID:94916
SHARE URLCan a state decide to be its own MMIS systems integrator?
CMS encourages the use of an SI outside the state agency, but states can consider themselves in that role if they can support that effort and if that decision is made with consultation and agreement from CMS. For more information about the role of the SI, see Section 1.7 in part 01 of MECT Medicaid Enterprise Certification Life Cycle. https://www.medicaid.gov/medicaid/data-and-systems/mect/index.html
FAQ ID:94921
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
SHARE URLIf a state is already using actual acquisition cost (AAC) as their reimbursement methodology, does the state need to file a State Plan Amendment (SPA) or provide assurances that the current formula meets requirements established in the final rule? Is there a requirement for such states to file a SPA to provide assurance that the state's current dispensing fee amount meets the requirements of the final rule?
If a state is already making payment for prescription drugs under its state plan based on AAC, it may continue to use that methodology. However, if a state decides to change its AAC model of reimbursement, (e.g., the state decides to use the National Average Drug Acquisition Cost (NADAC) instead of a state survey to implement a payment methodology based on AAC), the state must submit a new SPA through the formal SPA process for review.
Additionally, the state should review its currently approved professional dispensing fee (PDF) to determine if, in light of the regulation (42 CFR 447.518), the PDF needs to be revised and a SPA needs to be submitted. The state does not have to submit a new SPA to provide assurance that its dispensing fee is reasonable.
Furthermore, we expect that all states, even those currently operating under an AAC reimbursement methodology, will evaluate their current state plans to determine if a SPA will be required to comply with the reimbursement requirements (including, but not limited to, AAC, PDF, 340B and the federal upper limits (FULs)).
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94671
SHARE URLWill there be an annual review of PDFs that are required as part of SPA approvals?
No, CMS will not perform an annual review of PDFs; however, states must consider both the ingredient cost reimbursement and the PDF reimbursement when proposing changes to ensure that total reimbursement to the pharmacy provider is calculated in accordance with requirements of section 1902(a)(30)(A) of the Act.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94676
SHARE URLWill CMS be providing guidance to states to ensure that states include reasonable components in their cost of dispensing survey?
To the extent that a state is conducting a cost of dispensing survey, it should be a transparent, comprehensive, and well-designed tool that addresses a pharmacy provider's cost to dispense the drug product to a Medicaid beneficiary. States have the flexibility to set PDFs, including using national or regional data from another state and we do not require that a state use a specific standard or methodology such as a survey to do so.
Further, states are not required to use a specific formula or methodology such as a cost study or use an inflation update where cost studies are not conducted; however, the burden is on each state to ensure that pharmacy providers are reimbursed in accordance with the requirements in section 1902(a)(30)(A) of the Act. CMS will review each SPA submission against these standards (see 81 FR 5311).
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 205.53 KB)
FAQ ID:94681
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