Frequently Asked Questions

The UPL limits payment to the Medicare rate or cost. Providers paid at reconciled cost may receive no more than their reconciled amount. As a result, states cannot attribute the “UPL room” from other providers to pay additional amounts to any provider paid at reconciled cost. Due to this payment limitation, states should not include any provider paid at reconciled cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at reconciled cost and confirm by provider use of either a Medicare cost report or Centers for Medicare & Medicaid Services-approved cost report template to identify allowed cost. Further, states must document the ownership status (state owned, non-state government owned, or private) of each provider.

FAQ ID:92436

Regulation at 42 CFR 447.000(c)(1) and (2) specifies Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, or their successor codes.

FAQ ID:92126

The UPL limits payment to the Medicare rate or cost. Providers paid at cost may receive no more than their reconciled amount. As a result, states cannot attribute the "UPL room" from other providers to pay additional amounts to any provider paid at cost. Due to this payment limitation, states should not include any provider paid at cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at cost and, therefore, excluded from the calculation of the UPL.

FAQ ID:92396

The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.

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FAQ ID:92106

Technical assistance questions, as well as information about state Medicaid prevention efforts, can be directed to: MedicaidCHIPPrevention@cms.hhs.gov and/or Deirdra Stockmann, 410-786-2433.

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FAQ ID:91501

Any retroactive payments made to providers in order to ensure that eligible providers receive the applicable Medicare rate for eligible services will not be considered claims subject to the requirements in 42 CFR 447.46.

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FAQ ID:91411

While we recognize that health plans may have unique definitions of primary care providers and services, the availability of the increased Federal Medical Assistance Percentage (FMAP) is limited to the scope of eligible primary care providers and primary care services as defined in statute and implemented by this rule.

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FAQ ID:91416

CMS will be working collaboratively with the National Association of Medicaid Directors (NAMD) to develop the contract elements necessary to reflect the requirements of this rule. In recognition of the State Medicaid Agency's role in the contracting practice, CMS will describe the suggested content areas rather than issue standardized contractual language. These elements will be described in further detail in a future (Question and Answer) Q&A document.

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FAQ ID:91421

At this time, the Center for Medicare & Medicaid Services (CMS) is not defining the form of information required under 42 CFR 447.400(d)(1), but we do suggest that states with Medicaid managed care programs conduct a baseline assessment of primary care access before the provision goes into effect. This baseline assessment will ensure that Congress, CMS, and researchers have comparative data to evaluate this provision.

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FAQ ID:91426

In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a 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 Federal Medical Assistance Percentage (FMAP) rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act are applicable.

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FAQ ID:91076