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 one percentage point FMAP increase applies to the USPSTF grade A and B recommended services for the populations referenced in the recommendations.
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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.
For states who opt to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, for calendar years 2014-2016, the one percentage point increase for newly eligible individuals wouldn't apply, as the FMAP for that group is 100 percent.
Starting in 2017 and beyond, when the newly eligible FMAP goes to 95 percent and below, the one percentage point increase for the services mentioned in section 4106 of the Affordable Care Act would apply to the newly eligibles. Example: For 2017, newly eligibles would receive 95 percent FMAP. If the state opts to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, per the guidelines in State Medicaid Director Letter (SMDL) 13-002, the state would receive 96 percent FMAP on such services for the newly eligibles.
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Yes, that is correct. The one percentage point FMAP increase under section 4106 applies only to the FMAP set forth under section 1905(b) and section 1905(y) of the Act; it does not apply to FMAP rates under section 1903(a) of the Act. However, any family planning related service that also is recognized by section 4106 and matched at the state's regular FMAP is eligible to receive the one percentage point FMAP increase.
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If the state is meeting the requirements outlined in State Medical Director (SMD) letter #13-002, the state may receive the one percentage point FMAP increase on the Medicaid liability after coordination of benefits occurs.
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Clinical preventive services that receive an I or C recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover I or C recommended services. However, United States Preventive Task Force (USPSTF) grade I and C recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.
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Clinical preventive services that receive a D recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover D recommended services. However, United States Preventive Services Task Force (USPSTF) grade D recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.
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"Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment Final Rule" (CMS-2334-F), published in the Federal Register on 7/15/2013, conformed the regulatory definition of preventive services at § 440.130(c) with the statute relating to the issue of who can be providers of preventive services. Per the final rule, effective 1/1/2014, preventive services may be recommended by a physician or other licensed practitioner. Therefore, unlicensed practitioners will be able to furnish preventive services (including the services mentioned in section 4106), based on the recommendation of a physician or other licensed practitioner, according to the provider qualifications established by each respective state, within broad federal parameters. In order for states to receive the one percentage point federal medical assistance percentage (FMAP) increase for unlicensed practitioners, it is likely that a state plan amendment updating section (13)(c) of the state plan will be necessary. Please refer to the preventive service CMCS Informational Bulletin issued on November 27, 2013 for additional information regarding adding unlicensed practitioners to the preventive services section of the state plan.
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While section 4106 of the Affordable Care Act states that USPSTF grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration must be covered to secure the one percentage point FMAP increase, it is incumbent upon state Medicaid agencies to continue to work with, and communicate to, providers concerning state-specific systems and appropriate codes. The information provided by the American Medical Association in the below link (the CPT Code Pocket Guide: Preventive services with cost-sharing waived) can be used as a starting point in creating a cross-walk from the USPSTF and ACIP recommended codes, but it is not all-inclusive.
In addition, the October 2012 State Health Official (SHO) letter, gave the below web site address for HCPCS codes effective for service dates on or after January 1, 2012, and contacts within CMS for questions regarding HCPCS codes.
http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
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The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
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It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.
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