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
The final rule requires physicians to self-attest to an eligible specialty designation and to further indicate whether they are Board certified in an eligible specialty or subspecialty or 60 percent of the services for which they bill are for eligible Evaluation & Management (E&M) or vaccine administration codes. Annually, states must conduct a review of a statistically valid sample of physicians that have self-attested to either Board certification or a supporting claims/service history. Physicians and State Medicaid agencies must keep all information necessary to support an audit trail for services reimbursed at the higher rate.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91311
The Center for Medicare & Medicaid Services (CMS) will require that the state repay erroneous payments found through the sampled pool of providers, and will not extrapolate data from the sample to the entire universe of physicians who received the higher primary care payment. States with high error rates should submit a plan for corrective action to reduce errors.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91316
The final rule specifies that services must be delivered under the Medicaid physician services benefit. This means that higher payment also will be made for primary care services rendered by practitioners working under the personal supervision of a qualifying physician. The rule makes clear that, while deferring to state requirements regarding supervision, the expectation is that physicians assume professional responsibility for the services provided under their supervision. This usually means that the physicians are legally liable for the quality of the services provided by individuals they're supervising. If this is not the case, the practitioners would be viewed as practicing independently and would not be eligible for higher payments.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91321
PCCM payments are not eligible for higher payment under this rule.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91326
Higher payment does not apply to services provided under another Medicaid benefit category such as clinic or FQHC or RHC.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91331
Yes. This information will be made available on Medicaid.gov. States will be asked to verify the payment amount in effect for each of the billing codes affected by the final rule as of July 1, 2009.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91336
Yes. CMS has provided a preprint for the reimbursement section of the Medicaid state plan that will describe payment for evaluation and management services and vaccine administration. The preprint is available on Medicaid.gov.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91341
A state is not required to cover all of the primary care service billing codes if it did not previously do so. Rather, to the extent that it reimburses physicians using any of the billing codes specified in the final rule, the state must pay at the Medicare rate in the calendar years (CYs) 2013 and 2014.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91346
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91076
States have flexibility in establishing agreements with hospitals, structuring training programs and conducting oversight consistent with overall federal guidance and the goal of ensuring that hospital PE is available as a way for individuals to access coverage. Under the regulations, states must explain their PE policies and procedures to their qualified entities. To provide transparency into the states' approach to ensuring that qualified entities have information on state eligibility policies and procedures, states must describe their process as part of their state plan amendment (SPA) submission and include with their SPA copies of training materials, documents or other materials provided to qualified entities demonstrating that the state is fulfilling its responsibilities. To assist states, CMS has provided a model structure for training materials and examples from other states where hospital PE has been approved. CMS will review materials in draft form in order to facilitate the SPA review and approval process. Materials relating to hospital PE are available on Medicaid.gov at www.medicaid.gov/resources-for-states/medicaid-and-chip-mac-learning-collaboratives/index.html.
Supplemental Links:
Date: January 24, 2014
Topics:
Affordable Care Act
Subtopics:
Hospital Presumptive Eligibility
FAQ ID: 91466