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 needs to reduce durable medical equipment (DME) rates as a result of this requirement, is the state required to complete an Access Monitoring Review Plan as described in 42 CFR 447.203 and 447.204, which is required for state plan amendments that propose to reduce payments to Medicaid providers?
State Medicaid Director Letter #17-004 addressed this area by stating: “Reductions necessary to implement CMS federal Medicaid payment requirements (e.g., federal upper payment limits and financial participation limits), but only in circumstances under which the state is not exercising discretion as to how the requirement is implemented in rates. For example, if the federal statute or regulation imposes an aggregate upper payment limit that requires the state to reduce provider payments, the state should consider the impact of the payment reduction on access.” In addition, the long-standing policy of the Medicaid program has been that Medicare rates are sufficient to ensure access.
FAQ ID:93521
SHARE URLConsidering the differences between the Medicaid and Medicare populations, will limiting federal financial participation (FFP) for durable medical equipment (DME) cause hardship for people with disabilities in the Medicaid program?
We acknowledge that there are differences between the Medicare and Medicaid populations, but nothing in the policy guidance or statute compels states to reduce the items that states provide to people with disabilities under the state plan. As noted above, the statute does not expressly compel states to reduce the payment rates for DME. The statute limits the amount of money that the federal government will pay (i.e., FFP) for the relevant DME in the aggregate as compared with the relevant DME provided in the Medicare program. States retain the flexibility to make payments at rates that best serve the needs of their Medicaid beneficiaries.
FAQ ID:93526
SHARE URLWhat if I encounter an account that does not appear to fit into any of a state's eligibility coverage groups?
Applicants that indicate they have a disability, need long-term care or are over age 65 are always referred to the Medicaid agency for a determination on a non-MAGI basis, regardless of income and household composition, since the FFM is evaluating eligibility for MAGI-based eligibility groups only. Additionally, applicants may always request a full Medicaid determination at the end of the application process. In assessment states, the Medicaid agency will do a final determination of eligibility for these applicants, whereas in determination states, the Medicaid agency just needs to follow up for a non-MAGI determination. The expanded flat file will contain a specific indicator showing if the applicant requested a full determination.
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FAQ ID:92136
SHARE URLWhat information does CMS expect to be included in the Notes tab?
The Notes tab should include any and all information to fully support the state's UPL demonstration. CMS expects states to provide clarifying information in the Notes tab. For example, this information would provide details for the adjustments to Medicare as input in variables 212.1 and 212.2, various supplemental payments in variables 313.1, 313.2, and 313.3, and adjustments to Medicaid in variables 314.1 and 314.2. In addition to reporting through the notes tab, the state also has the option of using the guidance document or narrative to fully support its UPL demonstration.
FAQ ID:92376
SHARE URLCan states rely on the information contained in the enhanced flat files?
We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.
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FAQ ID:91906
SHARE URLWhat action may the state take if the state believes there is another basis for excluding an individual from flat file-based enrollment based on state analysis or external information?
If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.
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FAQ ID:91921
SHARE URLWhat if a state later determines that a person enrolled based on information in the flat file is not eligible for Medicaid or CHIP?
In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.
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FAQ ID:91926
SHARE URLWe understand that if we use the expanded flat file for enrollment, applicants are eligible to receive Medicaid for 90 days for assessment states and that we will run them through a MAGI-based determination in the future. If we enroll someone based on the flat file, and then become aware of additional information regarding the individual's eligibility before we receive the full account transfer, do we need to act on that information?
Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.
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FAQ ID:91931
SHARE URLIf an application contains a household which is a mixed case with MAGI and non-MAGI individuals, how should the state process enrollment in this situation?
Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid under the MAGI standard, the state can process enrollment for MAGI individuals under the waiver authority. Since the FFM is providing non-MAGI applicant referrals on the expanded flat file, the state would act upon the non-MAGI referrals in the same manner as it would through the account transfer service.
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FAQ ID:91936
SHARE URLWhat are the security requirements for receiving and acting upon the expanded flat file? Can we follow processes consistent with paper applications (logging starts once the information is entered into the eligibility system)?
Yes, all the regulations and security constraints that apply to paper applications are necessary with the expanded flat file. The state would need to maintain the same level of security for the expanded flat file as they would in regard to paper applications.
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FAQ ID:91941
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