Frequently Asked Questions

Attestation forms are developed by the State Medicaid agencies. Physicians should contact their state Medicaid agency for information on the process for becoming eligible for higher payment in their state.

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Yes, that is correct.

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Physicians must first self-attest to a primary care designation of internal medicine, family medicine or pediatrics. This attestation signifies that the physicians consider themselves to be eligible specialty practitioners. The self-attestation must then indicate whether the physicians consider themselves to be qualified because of appropriate Board certification or practice history as represented by a 60 percent claims history. Some physicians may be appropriately Board certified and have a 60 percent claims history.

There may be physicians with Board certification in a specialty not recognized for higher payment under the rule who actually practice as pediatricians, family practitioners or internists who would be eligible for higher payment. For example, an Obstetrician/Gynecologist (OB/GYN) who no longer practices in that specialty but practices as a family practitioner could appropriately self-attest to being a primary care provider. Such a provider would need to qualify based on the 60 percent threshold and not Board certification. Physicians that support their initial self-attestation with an attestation of appropriate Board certification can qualify only if they actually have the appropriate Board certification. Practice habits would not be applicable.

There may also be physicians with Board certification in one of the three eligible specialty areas who do not actually practice in those areas. They should not self-attest to being a primary care provider.

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The Center for Medicare & Medicaid Services (CMS) disseminated the Deloitte fee for service tool to states through the CMS Regional Offices in early January. It permits states to develop rates for each code based on the decisions it makes about site of service and geographic adjustments. The formula used to develop the rate weights each county equally and does not incorporate a weighting factor for population. Using a rate weighted by population is not an option for states to use in developing their fee schedules.

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CMS can produce the fee schedules for states that are unable to run the program. States should contact Christopher Thompson at Christopher.thompson@cms.hhs.gov.

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Yes.

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Beginning in 2014, the Affordable Care Act authorizes two types of increased federal medical assistance percentages (FMAPs) for state expenditures for low-income individuals in the new adult group (that is, the group described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (the Act)) - the newly eligible FMAP and the expansion state FMAP. Under the statute, these two increased federal matching rates are only available to states that adopt the new adult group.

The newly eligible FMAP is available for medical assistance expenditures on behalf of "newly eligible" individuals, who are defined (in section 1905(y)(2) of the Act) as individuals between the ages of 19 and 64 who are enrolled in the new adult group and who would not have been eligible for full benefits, benchmark coverage (described in subparagraph (A), (B), or (C) of section 1937(b)(1) of the Act), or benchmark-equivalent coverage (described in section 1937(b)(2) of the Act) as of December 1, 2009. An individual may also be "newly eligible" if he or she would have been eligible but could not have been enrolled for such benefits or coverage because the applicable Medicaid waiver or demonstration had limited or capped enrollment as of December 1, 2009.

The newly eligible FMAP (described in section 1905(y)(1) of the Act) is 100 percent in calendar years 2014-2016, 95 percent in calendar year 2017, 94 percent in calendar year 2018, 93 percent in calendar year 2019, and 90 percent in calendar years 2020 and beyond. The expansion state FMAP (described in section 1905(z)(2) of the Act) is an alternate increased FMAP available to match the expenditures for certain adults in states that previously expanded Medicaid and, as a result, may not qualify for the newly eligible FMAP. More details about the expansion state FMAP are included in Question 5. In our August 17, 2011 eligibility NPRM, we proposed that methods for assigning the appropriate FMAP would not require that states undertake the process of using their old eligibility rules to determine if someone would have been eligible under December 2009 rules. We have been consulting with states to test different methodologies for accuracy and simplicity.

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As described above, the newly eligible FMAP applies to adults in the new low-income adult eligibility group who would not have been eligible for full benefits, benchmark benefits, or benchmark-equivalent benefits under the state's rules as of December 1, 2009. At the time of approval of the section 1115 demonstrations in effect as of that date, neither CMS nor states explicitly designated the coverage offered under demonstrations as "benchmark" or "benchmark-equivalent" coverage, even though the coverage offered to demonstration beneficiaries may have met such standards. Therefore, CMS is requesting that states that used section 1115 demonstrations to expand coverage to low-income adults as of December 1, 2009 provide CMS with an analysis of the benefit package that was offered so that CMS can determine whether the benefits provided could have met a benchmark or benchmark equivalent standard, as in effect in December 2009. A separate analysis should be undertaken for each demonstration benefit package, if different demonstration populations received different benefits under the demonstration.

In conducting the benefit analysis, it will be important for states to utilize a consistent methodology and provide CMS with sufficient data to substantiate their analyses. States' benchmark-equivalence analyses must be certified by a qualified actuary and must include information on the data, assumptions, and methodology used to calculate actuarial values, in accordance with regulations implementing section 1937 of the Act, which are already in effect at 42 C.F.R. 440.330-340. CMS is working with all affected states (that is, states with demonstrations covering adults in effect on December 1, 2009) and will provide them with guidance about the form and manner in which to provide information about eligibility and benefits in effect as of December 1, 2009. CMS will use the benefit analysis that states provide to determine the appropriate FMAP. If any state has questions about this process, they should contact their State Operations and Technical Assistance (SOTA) team representative.

It is also important to note that if the benefit analysis described above indicates that the newly eligible FMAP is not available for a particular population, states may nevertheless be able to claim the expansion state FMAP for certain non-pregnant adults enrolled in the new adult group (as described in Question 5). CMS will work with each state that expanded coverage to adults prior to the enactment of the Affordable Care Act to address questions and to ensure that the correct FMAP is applied to expenditures for each population.

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When Congress enacted the Affordable Care Act, some states had already expanded coverage to adults at higher incomes. The expansion state designation under the statute provides an alternate increased FMAP to states that adopt the new adult group but where some individuals in the new group do not qualify for the newly eligible FMAP because they would have qualified for full benefits, benchmark benefits, or benchmark-equivalent benefits under the state's rules as of December 1, 2009. The expansion state FMAP may be available to qualifying states for expenditures for certain non-pregnant childless adults (those who are enrolled in the new adult group and who the state may require to enroll in benchmark coverage), to the extent that such individuals do not qualify for the newly eligible FMAP.

A qualifying expansion state (described in section 1905(z)(3) of the Act) is a state that, as of March 23, 2010 (the date of enactment of the Affordable Care Act), provided "health benefits coverage" either through Medicaid or a fully state-funded program to parents and nonpregnant childless adults up to at least 100 percent of the Federal Poverty Level (FPL). For purposes of this statutory definition, such health benefits coverage as of March 23, 2010 must have:

• Included inpatient hospital services.
• Not been dependent on access to employer coverage, employer contribution, or employment.
• Not been limited to premium assistance, hospital-only benefits, a high deductible health plan, or a health opportunity account

States seeking to confirm their status as expansion states should provide CMS with an analysis of the scope of coverage provided as of March 23, 2010, citing applicable demonstration special terms and conditions or state-based policies to establish eligibility levels and the coverage provided. As we have explained in a previously released FAQ, if a population covered by a state that qualifies as an expansion state meets the criteria for the newly eligible matching rate, the state will receive the newly eligible matching rate for that population. A state will always receive the more favorable FMAP if two FMAPs might be applicable for a particular population. For example, states that qualify as expansion states may be eligible for the newly eligible FMAP if the expansion offered less than full benefits, benchmark benefits, or benchmark-equivalent benefits, or if the expansion started after December 1, 2009. In such an instance, expenditures for adults in the new adult coverage group will be subject to the newly eligible FMAP. The expansion state FMAP (described in section 1905(z)(2) of the Act) is the regular FMAP rate increased by the number of percentage points equal to a "transition percentage" (which ranges from 50-100 percent) of the gap between the regular Medicaid FMAP and the increased "newly eligible" FMAP. In 2019 and beyond, the expansion state FMAP will be equal to the newly eligible FMAP, which means it will be 93 percent in 2019 and 90 percent in 2020 and thereafter.

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