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Frequently Asked Questions

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.

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Both the State Medicaid Director Letter describing the Substance Use Disorder (SUD) section 1115 demonstration opportunity and the Centers for Medicare & Medicaid Services (CMS) SUD Implementation Plan template, reference needs assessment tools and program standards established by the American Society for Addiction Medicine (ASAM). Is a state required to reference or rely on the ASAM Criteria in implementing an SUD section 1115 demonstration?

No, a state is not required to reference or rely on the ASAM Criteria however, states should use guidelines/patient placement tools that are comparable to ASAM criteria. The State Medicaid Director Letter describing the SUD section 1115 demonstration opportunity references the ASAM Criteria as a recognized standard and an example of a patient placement assessment tool that states could use. Participating states are expected to ensure that providers use an SUD-specific, multi-dimensional assessment tool in determining the types of treatments and level of care a beneficiary with an SUD may need. The ASAM Criteria is referenced as a representative example of such an assessment tool. 

Some states proposed alternative needs assessment tools. CMS reviews each alternative proposal on an individual basis, and CMS has so far determined that those alternatives are comparable to the ASAM Criteria and meet the expectations for this demonstration initiative. In addition, participating states are expected to implement provider qualifications for residential treatment providers that reflect well-established standards for these treatment settings. Again, the ASAM Criteria is referenced as an example of a resource that states may use for determining those standards.

FAQ ID:93681

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Which measures assess institutional rebalancing and utilization measures?

The following measures assess institutional rebalancing and utilization:

  • LTSS Admission to an Institution from the Community
  • LTSS Minimizing Institutional Length of Stay
  • LTSS Successful Transition after Long-Term Institutional Stay

FAQ ID:91101

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Do I need to use value sets to calculate these institutional rebalancing and utilization measures? If so, where can I find the value sets?

Yes. Value sets are the complete set of procedure and codes used to identify a service or condition included in a measure. All three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay—use the "Institutional Facility"value set (XLSX, 2.88 MB). See Table 2 in the "LTSS Value Sets to Codes" tab. Table 1 in the "LTSS Measures to Value Sets" tab shows each value set needed for each measure.

FAQ ID:91106

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Should unpaid or denied claims be included in calculating the institutional utilization and rebalancing measures?

No, include paid claims only (days denied for any reason should not be included) for all three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay.

FAQ ID:91111

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Are states only required to conduct Upper Payment Limit (UPL) demonstrations for services with approved state plan supplemental payment methodologies?

No, an upper payment limit demonstration considers all Medicaid payments (base and supplemental). States must conduct UPL demonstrations for the applicable services described in State Medicaid Director Letter (SMDL) 13-003 regardless of whether a state makes supplemental payments under the Medicaid state plan for the services.

FAQ ID:92191

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How and when should the Medicaid hospital tax/provider assessment be included in the inpatient hospital template?

The cost of the tax should be reported in Variable 401 - MCD Provider Tax Cost. A state may separately report the Medicaid portion of the cost of a provider assessment/tax only when it is using a cost based methodology to calculate the UPL. A state may not include this cost when calculating a DRG or Payment based UPL demonstration.

FAQ ID:92366

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What is the difference between "Medicaid Amount Reimbursed" vs. "Non-Medicaid Amount Reimbursed" in the State Drug Utilization Data (SDUD)?

A Non-Medicaid Reimbursed amount is any amount paid on a claim by parties other than Medicaid (e.g., other federal coverage, co-pay, private insurance). If a state receives Federal Financial Participation (FFP) for any part of a claim for a Covered Outpatient Drug (COD), that portion of the claim is included in the Medicaid Reimbursed amount. If a state does not receive FFP for any part of a rebate-eligible claim, then the amount of the claim is included in the Non-Medicaid Reimbursed amount.

FAQ ID:91981

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Why Does the "Medicaid Amount Reimbursed" and the "Non-Medicaid Amount Reimbursed" not equal the "Total Amount Reimbursed" in the State Drug Utilization Data (SDUD)?

The sum of the “Medicaid Amount Reimbursed” and the “Non-Medicaid Amount Reimbursed” fields should generally equal the Total Amount Reimbursed on a National Drug Code (NDC) by NDC basis; however, these new fields were implemented beginning with the fourth quarter of 2007 and are optional for the states to report prior to that time. Therefore, for quarters earlier than fourth quarter 2007, there may be some large discrepancies between the Total Amount Reimbursed and the sum of the Medicaid Amount Reimbursed and the Non-Medicaid Amount Reimbursed because the Non-Medicaid Amount Reimbursed is often not present for those earlier quarters. Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.

FAQ ID:91986

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Is the amount reimbursed by Medicaid net of rebates or pre-rebate in the State Drug Utilization Data (SDUD)?

Amounts reimbursed by Medicaid are pre-rebate, not net of rebates.

FAQ ID:92001

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Does the State Drug Utilization Data (SDUD) field "Units Reimbursed" represent the number of pills Medicaid paid for a drug that comes in a pill form?

"Units Reimbursed" are the number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state or, for MCO drugs, the number of units dispensed during the Quarter/Year. For more specific information, you may contact either the Drug Manufacturer or State via the contact lists.

FAQ ID:92016

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