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
Providers are permitted to charge a copay for a member's office visit. This visit may include a variety of services including preventive and non-preventive services. The State Medical Director (SMD) letter indicates the enhanced federal medical assistance percentage (FMAP) is available if cost-sharing is eliminated for preventive services. We believe this to mean that the doctor cannot collect a copay for any visit in which preventive services are provided, regardless of whether the majority of services provided during the visit are non-preventive services. We would like CMS verification.
If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.
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FAQ ID:92121
SHARE URLOne of the required fields in the Nursing Facility template is the Medicare Provider Number (Medicare Certification Number - Variable 112), but not all facilities are Medicare certified. How should data be entered for these facilities since it is a required field?
When a Medicare provider number is not available, such as for some nursing facilities, the state should populate variable 112 using the acronym NMC, which stands for "Not Medicare Certified". Adding this information will help to clearly identify the facility's status.
FAQ ID:92286
SHARE URLHow should more than two adjustments to the per diem be addressed in the nursing facility template for both Medicare and Medicaid Per Diem?
A state may report adjustments by using the following variables: Adjustments to Medicare Per Diem #1 - Variable 212.1 and Adjustments to Medicare Per Diem #2 - Variable 212.2 for the Medicare Per Diem and Adjustment to Medicaid Per Diem #1 - Variable 314.1 and Adjustment to Medicaid Per Diem #2 - Variable 314.2 for the Medicaid Per Diem. A state may report more than one adjustment under a single variable. For example, if the state has three adjustments to their Medicaid per diem, one of these adjustments can be reported in variable 314.1 and the other two adjustments can be added together and reported in variable 314.2. When reporting any adjustment, the state must provide a detailed description of the adjustment(s) in the notes tab.
FAQ ID:92296
SHARE URLHow should a state report Upper Payment Limit (UPL) data for out of state providers?
The UPL data for out of state providers does not need to be included in the UPL demonstration. If the state has provider level data then it may include it in the demonstration within the private ownership category of providers.
FAQ ID:92426
SHARE URLUnder section 4106 of the Affordable Care Act, is there a modifier to assist providers, payers and states in identifying preventive services?
The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
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FAQ ID:91991
SHARE URLUnder section 4106 of the Affordable Care Act, if the preventive service is bundled with other services, and the bundled service includes more than one preventive service, may the state allocate the bundled payment among the included services and claim the enhanced match for each of the preventive services? For example, in an annual exam, the physician provides both obesity counseling and alcohol misuse counseling. Can the state submit a claim for both the obesity counseling and the alcohol counseling?
It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.
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FAQ ID:91996
SHARE URLUnder section 4106 of the Affordable Care Act, are states required to follow only the summary of recommendations, or other information in the recommendation statement such as frequency? If the latter, reviewing potentially a ten-year claims history (e.g. for a colonoscopy) will be extremely burdensome.
Provided that the services are medically necessary, states are required to follow only the summary of recommendations for the services that have a rating of A or B from the United States Preventive Services Task Force (USPSTF). It is up to the state to have a financial monitoring procedure to ensure proper claiming for federal match.
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FAQ ID:92006
SHARE URLUnder section 4106 of the Affordable Care Act, for breast screenings, may the state claim the interpretation of the x-ray for the one percentage point federal medical assistance percentage (FMAP) increase, or can only the x-ray itself be claimed?
The state may claim the 1% FMAP increase on both the professional component (interpretation of the x-ray) and the technical component (the actual taking of the x-ray).
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FAQ ID:92011
SHARE URLUnder section 4106 of the Affordable Care Act, what information is being required for the CMS-64 reporting requirement to claim the increased federal medical assistance percentage (FMAP) for managed care expenditures?
States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all United States Preventive Services Task Force (USPSTF) grade A and B preventive services and approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP), and their administration, without cost-sharing. An approved state plan amendment is required for the lines to be enterable on the CMS-64 form. As with all other services claimed on the CMS-64, the amounts reported on and its attachments must be actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. The CMS-64 report form has been modified to allow for reporting of a state's managed care expenditures separate from the state's reporting of fee-for-service (FFS) expenditures. The total expenditures associated with services referenced in section 4106 would be reported on the requisite lines for managed care (line 18A4, 18B1d or 18B2d) and for FFS (line 34A).
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FAQ ID:92021
SHARE URLWhat federal matching rate will apply for services for which a higher payment is made under section 1202 of the Affordable Care Act, if the services also qualify for a higher federal medical assistance percentage (FMAP) under the provisions of section 4106 of the Affordable Care Act?
States that elect to cover all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and vaccine administration, without cost-sharing and who receive a SPA approval for such services shall receive the one percentage point FMAP increase per section 4106. Some of these services may also qualify as primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services, the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular FMAP rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act were followed.
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FAQ ID:92031
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