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
Under 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
SHARE URLUnder section 4106 of the Affordable Care Act, what diagnosis codes must be billed in order to claim the 1% federal medical assistance percentage (FMAP) increase (the United States Preventive Services Task Force (USPSTF) A and B does provide a list of codes - should we limit our review to them)?Are we required to make sure these services are for preventive screening and not for disease diagnosis? For example, anemia testing in pregnant women can be part of routine prenatal care, and a provider may order it later in a pregnancy if the woman complains of fatigue.The same service may be screening or diagnostic. How does CMS want states to differentiate? For example, we will pay a lab claim for a lipid panel. Having to match with the International Classification of Diseases (ICD) code (e.g. the presence or absence of hyperlipidemia) is burdensome, and ICD code may reflect either existing condition or purpose of ruling out that condition.The Medicaid billing codes associated with the eligible preventive services verify that a service was provided; they do not differentiate between services that are provided for preventive reasons and services that are provided for diagnosis maintenance. We would like CMS guidance on how this differentiation is to be identified.
As long as the state covers all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing, such services will be eligible for the one percentage point federal medical assistance percentage (FMAP) increase. State Medicaid agencies should work with, and communicate to, providers concerning state-specific systems and the appropriate codes to use.
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FAQ ID:92041
SHARE URLUnder section 4106 of the Affordable Care Act, if our program expects that a particular screening be done as part of an Evaluation and Management (E&M) coded visit, how does that relate to CMS coverage expectations? Counseling and verbal screening are often incorporated into an E&M visit. Does CMS require that states have distinct coding and reimbursement rates for physician time spent: 1) measuring blood pressure 2) counseling about alcohol misuse 3) making a referral for BRCA screening 4) discussing breast cancer chemoprevention 5) counseling on breastfeeding 6) prescribing oral fluoride 7) screening for depression 8) screening for intimate partner violence 9) screening for obesity 10) counseling to prevent skin cancer 11) counseling on tobacco cessation
We recognize that an E&M service may include a United States Preventive Services Task Force (USPSTF) grade A or B service (for example, blood pressure screening). To receive the one percentage point federal medical assistance percentage (FMAP) increase, states are required to cover in their standard Medicaid benefit package all USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing. It is up to the state to determine how the billing should occur. In the examples mentioned above, if you consider these USPSTF grade A or B recommended services to be an integral part of the office visit, and they will not be billed separately, the state may continue that billing practice. The state may claim the one percentage point FMAP increase on the office visit only if the primary purpose of the office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. The state should work with providers and payers to ensure that Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services are followed. We wish to confirm that a state must be able to document expenditures claimed on the CMS-64 and we believe the best way to accomplish this is through the billing process.
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FAQ ID:92046
SHARE URLPer state statute, my state currently covers breast cancer screenings at the United States Preventive Services Task Force (USPSTF) Grade C level. Breast cancer screenings are on the USPSTF list as a Grade B service with a different periodicity level.Under section 4106 of the Affordable Care Act, will we still be eligible for the 1% federal medical assistance percentage (FMAP) increase if we cover the breast cancer screening at the USPSTF Grade C level, but cover all of the other USPSTF Grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration without cost-sharing?
All USPSTF grade A and B services, and ACIP recommended vaccines and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase. The Department of Health and Human Services, in implementing the Affordable Care Act under the standard set out in revised section 2713(a)(5) of the Public Health Service Act, utilizes the 2002 recommendations on breast cancer screening of the USPSTF. Therefore, we are adopting a flexible approach for states to receive a one percentage point FMAP increase for breast cancer screening. States can choose to use either the 2002 USPSTF grade B recommendation or the most current USPSTF recommendation (which is the grade B recommendation updated in 2009). The 2002 USPSTF recommendation is that women age 40 years and older should receive a screening mammography everyone to two years. The 2009 USPSTF recommends biennial screening mammography for women aged 50 to 74 years of age.
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FAQ ID:92056
SHARE URLThe state is under the impression that they only need to update the 3.1-A coverage pages for preventive services to claim the 1% federal medical assistance percentage (FMAP) increase under section 4106 of the Affordable Care Act. Does the state need to update their reimbursement pages as well to provide the required assurances?Can you please advise if CMS will require public notice in addition to the state plan amendment (SPA) for the 1% FMAP increase to take effect?
In order to receive the one percentage point FMAP increase, the state is required to submit a SPA with updated coverage pages. When a SPA is submitted with updated coverage pages, we will perform a review of the corresponding payment page(s). A state does not need to submit a SPA with revised payment pages, and conduct public notice, unless it wishes either to begin coverage and payment for these services or to change the existing payment rates (in other words, if the state already pays for the preventive services in some contexts, a payment SPA may not be needed if the state does not want to change the existing payment rate or methodology).
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FAQ ID:91516
SHARE URLUnder what portion of the state plan should the state add the Affordable Care Act section 4106 information?
The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.
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FAQ ID:91521
SHARE URLDoes a state that has both a fee-for-service (FFS) and a managed care delivery system, get the 1% federal medical assistance percentage (FMAP) increase when just the FFS benefit is amended or would the state have to concurrently amend its managed care authority document (state plan amendment (SPA), waiver or 1115 demonstration project) to get the 1% FMAP increase under section 4106 of the Affordable Care Act?
A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit. To claim that enhanced FMAP for managed care payments, CMS must review the methodology that the state intends to use to estimate the value of the preventive services benefit in its capitation rates.
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FAQ ID:91526
SHARE URLAccording to the United States Preventive Services Task Force (USPSTF) methodology "The Task Force also aims to update topics every five years, in order to keep recommendations in the Task Force library current according to criteria established by the National Guideline Clearinghouse. Under section 4016 of the Affordable Care Act, does the requirement of covering and claiming increased federal financial participation (FFP) for USPSTF A and B recommendations apply only to recommendations that are new, updated, or reaffirmed within the past five years?
Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.
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FAQ ID:91531
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