Frequently Asked Questions

For purposes of the federal financial participation (FFP) limit, Medicare claims volume will not be considered in the demonstration of the limit. Only Medicaid claims volume is relevant for the calculation of the FFP limit.

The Centers for Medicare & Medicaid Services (CMS) will analyze state data provided to CMS and return the detailed information comparing the data sent from the state to the lowest and average Medicare rates for the relevant DME in the state on the aggregate. CMS will work with states during 2018 to assist with reporting necessary information under the new statute, and will run data reports for states before the end of the year if requested. A state that wishes this review should contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.

States are not required to change how they pay for items because of the statute. If a Medicaid program only purchases Medicare capped rental items, then that is the payment and utilization we will compare to Medicare’s rates in determining the aggregate expenditures. States are not obligated to alter their coverage of durable medical equipment due to the statute.

For the aggregate demonstration of Medicaid expenditures, we intend to use the Medicare rates released for services on or after January 1 of each year. We would suggest that states setting their rates according to Medicare rates in the state plan would follow a similar practice. States are, of course, welcome to use the quarterly updates of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) if that’s their intention, but we are not requiring those rate updates beyond the January 1 DMEPOS update.

For technical assistance with the implementation efforts and assistance with determining if current state practices are below the FFP limit, please contact the Medicaid DME mailbox: MedicaidDME@cms.hhs.gov.

States may review Medicare’s CBAs through the following website for the most up-to-date information: www.dmecompetitivebid.com. In the alternative, the Center for Medicaid and CHIP Services (CMCS) has a list of states and CBAs by state that is available upon request. We will monitor the lists and update them with any necessary Medicare changes. As of January 1, 2018, the following states and territories do not have CBAs: Alaska, Maine, Vermont, North Dakota, South Dakota, Montana, Wyoming, and all of the US territories.

Each state Medicaid and CHIP program has its own provider network. Contact your state for a list of providers.

Contact your state Medicaid agency. They can help you get replacement cards and answer your questions about what services are covered, providers to use, and how to renew your eligibility.

The statute and regulations require that states provide individuals several channels through which they can apply for Medicaid and CHIP coverage - by mail, in person, on line and over the telephone. Following are some guiding principles for administering telephonic applications based on successful strategies many states have in place today.

1. Accepting a Telephonic Application - States may develop their own processes for accepting and adjudicating telephonic applications. The process for accepting applications by phone must be designed to gather data into a sufficient format that will be accessible for account transfer to the appropriate insurance affordability program. For example, a customer service representative could verbally communicate application questions to the applicant, while electronically filling out the online version of the single streamlined application.
2. Voice Signatures - All applications must be signed (under penalty of perjury) in order to complete an eligibility determination. In the case of telephonic applications, states must have a process in place to assist individuals in applying by phone and be able to accept telephonically recorded signatures at the time of application submission. If applicable, states can maintain their current practices of audio recording and accepting voice signatures as required for identity proofing.
3. Records and Storage - Upon request, states must be able to provide individuals with a record of their completed application, including all information used to make the eligibility determination. As such, CMS recommends that states record all telephonic applications. This may be accomplished by taping the complete application transaction as an audio file, or by producing a written transcript of the application transaction, among other options. The length of storage of these records should comply with current regulations on application storage.
4. Confirmations and Receipts - States should provide a confirmation receipt documenting the telephonic application to the applicant. Such confirmation should be provided upon submission of the application or at any time the applicant wishes to end the customer representative interaction. Confirmation receipts can be delivered via electronic or paper mail (based on the applicant's preference). Confirmation receipts must include key information for applicants, including but not limited to the application summary, the eligibility determination summary page, a copy of the attestations/rights and responsibilities and the submission date of the signed application.

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If a woman is enrolled in a group for pregnant women, before the end of the post-partum period, as specified in the definition of "pregnant woman" at 42 CFR 435.4, the state Medicaid agency will need to re-evaluate the woman's eligibility for other groups, including the lowincome adult group and advance payment of premium tax credits through the Marketplace. Our regulations at 42 CFR 435.916 explain the requirements for states in connection with renewals of eligibility or determinations of ineligibility based on a change in circumstances. The procedures outlined in the regulation are intended to promote continuity of coverage.

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• This FAQ was released as part of a larger set. View the full set.