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
States may only claim the one percentage point FMAP increase on services that adhere to the USPSTF grade A and B recommendations on age, gender, periodicity and other criteria as indicated in the summary of recommendations. For instances where the USPSTF grade A and B recommendations have expanded age, gender or periodicity levels due to clinical considerations, practitioners should document in the patient's medical record the necessity for exceeding the grade A and B recommendations, and states may claim the one percentage point FMAP increase. When billing for these services, payers may want to use modifier 33 to identify services that meet the criteria for the USPSTF grade A and B recommendations. Pursuant to page 2 of State Medical Director (SMD) letter #13-002, states should have a financial monitoring procedure in place to ensure proper claiming for federal match.
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For states seeking the one percentage point federal medical assistance percentage (FMAP) increase, the SPA requirements are indicated on pages 3 and 4 of the State Medicaid Director (SMD) letter #13-002. CMS will not provide a state plan template on section 4106 of the Affordable Care Act. However, staff are available to provide technical assistance prior to your SPA submission.
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All USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase.
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The United States Preventive Services Task Force (USPSTF) recommendation for tobacco use counseling for pregnant women is grade A. Therefore, tobacco use counseling for pregnant women shall receive the one percentage point increase in FMAP. In addition, section 4106 of the Affordable Care Act states "items and services described in subsection (a)(4)(D)". Therefore, the one percentage point increase pertains to the comprehensive tobacco cessation services for pregnant women that are described in section 4107 of the Affordable Care Act.
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The statute amended section 1905(b) of the Social Security Act (Act) only to provide for the higher federal matching rate for services and vaccines described in subparagraphs (A) and (B) of section 1905(a)(13) of the Act . These subparagraphs are limited to "clinical preventive services assigned a grade of A or B by the United States Preventive Services Task Force (USPSTF), adult vaccinations, and comprehensive tobacco cessation for pregnant women. This is a subset of the services described in section 1905(a)(13) of the Act.
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Section 1905(a)(13)(B) of the Act is limited to adult vaccines, therefore, the following applies:
- Children age 18 and under: Vaccines are provided through the VCF program. Therefore, the one percentage point increase does not apply. For this age group, the vaccine administration fee is not eligible for the one percentage point FMAP increase.
- Individuals age 19 and 20: Vaccines are not available through the VCF program for this age group. This age group may receive the one percentage point increase in FMAP on both the vaccines and the vaccine administration fee.
- Adults ages 21 and older: Both the Advisory Committee on Immunization Practices (ACIP) recommended vaccines and the vaccine administration fee are eligible for the one percentage point increase in FMAP.
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States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all United States Preventive Services Task Force (USPSTF) grade A and B preventive services and approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP), and their administration, without cost-sharing. An approved state plan amendment is required for the lines to be enterable on the CMS-64 form. As with all other services claimed on the CMS-64, the amounts reported on and its attachments must be actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. The CMS-64 report form has been modified to allow for reporting of a state's managed care expenditures separate from the state's reporting of fee-for-service (FFS) expenditures. The total expenditures associated with services referenced in section 4106 would be reported on the requisite lines for managed care (line 18A4, 18B1d or 18B2d) and for FFS (line 34A).
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States that elect to cover all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and vaccine administration, without cost-sharing and who receive a SPA approval for such services shall receive the one percentage point FMAP increase per section 4106. Some of these services may also qualify as 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 FMAP rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act were followed.
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As long as the state covers all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing, such services will be eligible for the one percentage point federal medical assistance percentage (FMAP) increase. State Medicaid agencies should work with, and communicate to, providers concerning state-specific systems and the appropriate codes to use.
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We recognize that an E&M service may include a United States Preventive Services Task Force (USPSTF) grade A or B service (for example, blood pressure screening). To receive the one percentage point federal medical assistance percentage (FMAP) increase, states are required to cover in their standard Medicaid benefit package all USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing. It is up to the state to determine how the billing should occur. In the examples mentioned above, if you consider these USPSTF grade A or B recommended services to be an integral part of the office visit, and they will not be billed separately, the state may continue that billing practice. The state may claim the one percentage point FMAP increase on the office visit only if the primary purpose of the office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. The state should work with providers and payers to ensure that Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services are followed. We wish to confirm that a state must be able to document expenditures claimed on the CMS-64 and we believe the best way to accomplish this is through the billing process.
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