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
When will the Basic Health Program be operational?
Given the scope of the coverage changes that states and the federal government will be implementing on January 1, 2014, and the value of building on the experience that will be gained from those changes, HHS expects to issue proposed rules regarding the Basic Health Program for comment in 2013 and final guidance in 2014, so that the program will be operational beginning in 2015 for states interested in pursuing this option.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)
FAQ ID:92141
SHARE URLWhat approaches are available to states that are interested in the Basic Health Program in the interim?
HHS is working with states that are interested in the concepts included in the Basic Health Program option to identify similar flexibilities to design coverage systems for 2014, such as continuity of coverage as individuals' income changes. Specifically, we have outlined options to states related to using Medicaid funds to purchase coverage through a Qualified Health Plan (QHP) on the Marketplace for Medicaid beneficiaries (PDF, 242.79 KB). Additionally, some states with current Medicaid adult coverage expansions are considering offering additional types of assistance with premiums to individuals who will be enrolled in QHPs through the Marketplace. HHS will review all such ideas.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 135.35 KB)
FAQ ID:92146
SHARE URLHow is the demonstration year defined? For example, if a state has a fiscal year starting on July 1, 2016 and ending on June 30, 2017, is the Upper Payment Limit (UPL) demonstration entered with the SFY 2016/17 State Plan Amendment considered to be a "2016 demonstration" or a "2017 demonstration"?
The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.
FAQ ID:92231
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 a state review providers whose claims meet the 60 percent threshold and assume that those providers would be automatically eligible?
Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
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FAQ ID:94276
SHARE URLCMS clarified in the final rule for CMS 2370-F that, for out of state providers, the beneficiary's home state (e.g., state A) may defer to the determination of the physician's home state (e.g., state B) with respect to eligibility for higher payment. However, if states A and B receive different Medicare locality adjustments, which locality rate must be paid?
As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.
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FAQ ID:94361
SHARE URLWhen does the Centers for Medicare & Medicaid Services (CMS) plan to issue a correction to the mistake they noted during the call with Medicaid agencies regarding payment under CMS 2370-F at the lesser of a provider's billed charge or the Medicare rate?
The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.
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FAQ ID:94376
SHARE URLIf a physician presents a certificate for CMS 2370-F eligibility from one of the defined boards, can the certificate be used as the legal document verifying the physician's certification or does the State have to verify with the board that the physician is certified and that the presented certificate is still active and valid?
States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.
FAQ ID:92686
SHARE URLThe final rule for CMS 2370-F indicated that 100 percent Federal Financial Participation (FFP) is not available for stand-alone Children's Health Insurance Program (CHIP) plans. What criteria should be used to determine if a plan is a stand-alone CHIP plan? What agency will determine if a plan is a stand-alone CHIP plan?
The Center for Medicare & Medicaid Services (CMS) approves CHIP programs as stand-alone or Medicaid expansions. Information on whether or not a particular state operates a stand-alone or expansion program is available at http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Downloads/Map-CHIP-Program-Designs-by-State-.pdf (PDF, 120.65 KB).
FAQ ID:92696
SHARE URLFederally qualified health centers (FQHCs)/ rural health clinics (RHCs) which receive an encounter rate are excluded under the rule for CMS-2370 F. Are FQHCs/RHCs who are paid provider fee-for-service included in the increase?
FQHCs and RHCs are required by law to be paid at least prospective payment system (PPS) for core primary care services. Physician services are core FQHC and RHC services and, therefore, should not be reimbursed on a fee-for-service basis.
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FAQ ID:92701
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