The federal financial participation (FFP) limitation imposed by section 1903(i)(27) of the Act applies only with respect to those items of durable medical equipment (DME) covered by a state’s Medicaid program that are also covered by Medicare. Items covered as DME by only one of the programs are not included. This statutory limitation also does not apply to items for which Medicaid is not the primary payer. The statute refers to state expenditures for DME, therefore all funds expended by the state Medicaid agency on purchasing the relevant DME items and for which the state is requesting federal matching funds needs to be accounted for in the demonstration. CMS suggests taking the entire amount spent on a certain DME item (i.e., per Healthcare Common Procedure Coding System code) and divide it by the total volume to get an average price per DME item for the purpose of the calculation tool. If states have specific questions please contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.
Date
Sub Topic
FAQ ID
93576
FAQ Page
FAQ Question
When the Centers for Medicare & Medicaid Services (CMS) references "state payment rate," do you mean the fee schedule rate or the average paid amount for that procedure code? For various reasons procedure codes are often paid less than the product of the fee schedule and the volume (e.g., the provider bills lower than the fee schedule, copays, third party liability, etc.).