Frequently Asked Questions

Preventive services include immunizations, screenings for common chronic and infectious diseases and cancers, clinical and behavioral interventions to manage chronic disease and reduce associated risks, and counseling to support healthy living and self-management of chronic conditions, such as those associated with obesity. A list of preventive health care services recommended as Grade A or B by the U.S. Preventive Services Task Force can be found at: https://www.uspreventiveservicestaskforce.org/uspstf/.

Through Medicaid's children's benefit - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - children under age 21 enrolled in Medicaid are assured coverage for preventive and comprehensive health services. States cover adult preventive services within Medicaid through both mandatory and optional benefit categories. Some preventive services (such as those related to family planning) may be defined in a state's mandatory set of benefits while others may be included in the optional benefit category. As a result, Medicaid programs differ from state to state on the coverage of preventive services for adults.

Obesity-related services are those services that help prevent and manage unhealthy weight. Medicaid and CHIP programs can cover a range of services to prevent and reduce obesity including Body Mass Index (BMI) screening, education and counseling on nutrition and physical activity, prescription drugs that promote weight loss, and, as appropriate, bariatric surgery.

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Affordable Care Act Section 4004(i)(2) calls for "state public awareness campaigns to educate Medicaid enrollees regarding availability and coverage of preventive and obesity related services with the goal of reducing incidences of obesity." The statute tasks states with designing the public awareness campaign because states have a better understanding of what outreach efforts will best meet the needs of their state Medicaid and CHIP population. Activities that provide information to beneficiaries about the preventive and obesity-related services covered in the state's Medicaid and CHIP programs will satisfy the requirement. Federal funding would be available for such activities as administrative costs of the Medicaid and CHIP programs.

Some resources that states may want to consider as they move forward with their activities include:

• Healthy Start page on the Health Resources and Services Administration's website
• Centers for Disease Control and Prevention's Nutrition, Physical Activity and Obesity
• "F as in Fat: How Obesity Threatens America's Future 2012," issued by the Trust for America's Health and the Robert Wood Johnson Foundation

States can receive the 50 percent Medicaid administrative matching rate for public awareness campaign activities, and will receive their existing Federal Medical Assistance Percentage (FMAP) rate for preventive services.

The Affordable Care Act includes additional funding for states that cover Grade A and B recommended services of the US Preventive Services Task Force (USPSTF) and all Advisory Committee on Immunization Practices (ACIP) recommended adult vaccines and their administration without cost sharing. CMS has released separate guidance on that provision which can be found at https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SMD-13-002.pdf.

In addition, CMS can provide technical assistance to states with reporting and interventions that they have in place to improve performance on the prevention core measures.

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Yes, if a state has undertaken an initiative to provide information on Medicaid coverage of preventive services since the passage of the Affordable Care Act in March 2010 then they have met this requirement.

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Yes, 75 percent FFP is available for ongoing costs of operating approved eligibility determination systems, often referred to as "E&E" systems, that meet the Standards and Conditions for Medicaid IT and critical success factors. (See: State Medicaid Director Letter on APD Requirements dated June 27, 2016 (SMD# 16-009), to be found at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.

Section 1903(a)(3)(B) of the Social Security Act provides 75 percent FFP for costs associated with operating an approved Medicaid management information system (MMIS). The Medicaid manual further clarifies at Section 11276.3 A. MMIS Operations, "FFP at 75 percent is available for direct costs directly attributable to the Medicaid program for ongoing automated processing of claims, payments, and reports. Included are forms, use of system hardware and supplies, maintenance of software and documentation, and personnel costs of operations control clerks, suspense and/or exception claims processing clerks, data entry operators, microfilm operators, terminal operators, peripheral equipment operators, computer operators, and claims coding clerks if the coded data is used in the MMIS, and all direct costs specifically identified to these cost objectives. Report users, such as staff who perform follow-up investigations, are not considered part of the MMIS."

States may claim 75 percent FFP for the costs of certain personnel closely associated with operating claims processing and related systems under MMIS. As noted in our final rule, Medicaid Program; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities (CMS-2346-F), in response to comments, "enhanced funding is available for staff time spent on mechanized eligibility determination systems in the same manner that they apply to all mechanized claims processing and information retrieval systems, since mechanized eligibility determination systems are now considered to be part of such systems, assuming the requirements of this section are met." (See: https://www.federalregister.gov/articles/2011/04/19/2011-9340/medicaid-program-federalfunding-for-medicaid-eligibility-determination-and-enrollment-activities ).H59 Additional information on FFP rates, including tables delineating specific covered costs, is available in the State Medicaid Director Letter on Enhanced Funding dated March 31, 2016 (SMD# 16-004), to be found at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.

States should work closely with CMS during the APD process to provide appropriate documentation concerning their cost allocation and claiming plans. In states where workers determine eligibility or provide customer service for multiple health and human service programs, costs should be allocated across programs, as discussed further in FAQ# 40811.

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Eligibility for the enhanced FFP will be based on state systems being compliant with the Standards and Conditions for Medicaid IT, including meeting minimum critical success factors for accepting the new single streamlined application, making MAGI-based determinations and coordinating with Marketplaces. The 75 percent FFP will generally be available when the approved system becomes operational. The 75 percent FFP will not expire.
The start date for the 75 percent FFP for maintenance and operations is the actual start of the operations of the approved eligibility determination system (also referred to as "E&E" system).

We recognize states may be phasing in system upgrades that implement modified adjusted gross income (MAGI)-based eligibility determinations first, with subsequent releases to include non-MAGI and/or other human services programs eligibility. We will allow the 75 percent FFP to begin with the start of the approved MAGI shared eligibility service, based upon an approved Operations APD, that meets the critical success factors. Further, states with challenges in meeting critical success factors at the expected service level must have approved mitigation strategies in order to qualify.

In order to begin claiming, states should submit an Operations APD to CMS that clearly identifies the functions, staff and costs to be charged at the 75 percent FFP level, and it must be approved by CMS before a state can begin claiming the enhanced match.

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Costs associated with the training of eligibility workers directly engaged in the operation of the new eligibility system may be eligible to be matched at the enhanced rate during the three months (or less) prior to the start of operations. An APD update would be required to document the costs, scope and timing of the training period, which will be reviewed and approved by CMS prior to a state being eligible to claim the enhanced match. States must be able to demonstrate their eligibility determination (also known as "E&E") system will be operationally ready, comply with the Standards and Conditions for Medicaid IT, and meet minimum critical success factors in order to claim the enhanced funding during this training period.

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Yes. Certain types of personnel costs are eligible for the 75 percent matching rate, subject to current MMIS maintenance and operations claiming rules. The State Medicaid Manual delineates which types of personnel costs can be claimed at enhanced match, including staff direct labor and fringe benefit costs. Only direct costs allocable to the development or operation of an MMIS (including Medicaid eligibility determination system) are eligible for reimbursement at enhanced FFP rates. Such costs include: utilities, rent, telephone service, etc., necessitated by either the development or operation of an MMIS or eligibility determination system. Costs which cannot be specifically identified with the development or operation of an MMIS (including Medicaid eligibility determination system) are matched at 50 percent FFP.

Such costs are usually indirect costs including the staff costs associated with agency-wide functions such as accounting, budgeting, and general administration.

The state must submit an Operations APD which includes an allocation or distribution plan showing the breakout of direct and indirect costs for equipment, supplies, and non-personnel resources it intends to claim, and justification for those.

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In situations where eligibility workers determine eligibility for multiple programs, all costs must be distributed to the appropriate programs and governing FFP rates (90/75/50) based on approved time study methodologies and/or cost allocation plans consistent with OMB Circular A-87 cost allocation principles. These costs must also clearly differentiate between resources needed for direct data and systems-related activities and resources needed for MMIS and eligibility determination systems versus program management and oversight activities, which are only eligible for 50 percent FFP. State agencies performing eligibility determination currently develop and maintain methodologies for allocating costs among different health and human services programs. CMS does not anticipate the additional reporting required to obtain 75 percent FFP will add a significant amount of time to that process. From 45 CFR section 95.507, Plan requirements, the cost allocation support should include the following:

• A description of the procedures used to identify, measure, and allocate all costs to each of the programs
• Conform to the accounting principles and standards prescribed in Office of Management and Budget Circular A-87, and other pertinent Department regulations and instructions;
• Contain sufficient information in such detail to make an informed judgment on the correctness and fairness of the state's procedures for identifying, measuring, and allocating the costs
• The cost allocation plan shall contain the following information:
  • An organizational chart showing the placement of each unit whose costs are charged to the programs operated by the state agency
  • A listing of all federal and all non-federal programs performed, administered, or serviced by these organizational units.
  • A description of the activities performed by each organizational unit and, where not self-explanatory an explanation of the benefits provided to federal programs.
  • The procedures used to identify, measure, and allocate all costs to each benefiting program and activity (including activities subject to different rates of FFP).

States should consult with their CMS cost allocation leads to determine whether any change to their approved cost allocation plan is needed and work with their counterparts at human services agencies as necessary. The methods of cost allocation should be documented in the state operations APD update submission to support the proposed budget.

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As noted earlier, states must submit an Operations APD to request this funding. CMS will monitor state implementation of the enhanced 75 percent FFP through ongoing review of state eligibility system implementation and operations, as well as through revised claims reporting. Specifically, CMS is revising the CMS-64-10 and 37-10 forms to separately capture eligibility determination system related maintenance and operations costs. We will separately track costs related to IT systems and eligibility determination staff as follows:

• For the IT and systems maintenance and operations, costs will be reported on the CMS-64-10 and 37-10 on line 28C - Operation of an approved Medicaid eligibility determination system/cost of in-house activities - 75 percent FFP and 28D - Operation of an approved Medicaid eligibility determination system/cost private sector contractors- 75 percent FFP.
• For the Eligibility Determination workers staffing eligible for enhanced match, costs will be reported on the CMS-64-10 and 37-10 on line 28E - Eligibility Determination staff - cost of in-house activities - 75 percent FFP and 28F- Eligibility Determination staff - cost of private sector contractors - 75 percent FFP.
• For the Eligibility Determinations workers staffing eligible for regular administrative match, costs will be reported on the CMS-64-10 and 37-10 on line 28G - Eligibility Determination staff - cost of in-hour activities - 50 percent FFP and 28 H - cost of private sector contractors - 50 percent FFP.

As this enhanced match is implemented, CMS will closely monitor implementation and reporting, and if necessary, will revise how this data is collected on the estimate and expenditure reporting forms to ensure states and CMS have the proper break out to track these activities and their related claims.

Furthermore, CMS will continue to work with states over time to ensure that their systems continue to remain compliant with the Seven Conditions and Standards. For example, under the Reporting Condition, state systems should be able to produce accurate data that are necessary for oversight, administration, evaluation, integrity and transparency. CMS has recently provided technical specifications for the Transformed Medicaid Statistical Information System (TMSIS) data file to states following more than a year of collaboration with states participating in the T-MSIS pilot. CMS envisions that the T-MSIS data file will be submitted on a monthly basis. We anticipate releasing additional guidance on this subject in the coming weeks.

As with all expenditures, federal match must be properly claimed and is subject to review and approval. Again, CMS will work closely with the each state to review and approve costs covered and will use the APD process to confirm with states specific implementation details, before states start to submit claims.

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In an assessment model, the Federally-Facilitated Marketplace will not make a final Medicaid determination. Instead, the Federally-Facilitated Marketplace will transmit the account to the Medicaid or CHIP agency when they have evaluated the individual and identified him or her as Medicaid or CHIP eligible, and the Medicaid or CHIP agency will make the formal determination. In a determination model, the Medicaid or CHIP agency delegate the authority to make determinations to the Federally-Facilitated Marketplace. In both an assessment and determination model, as described in more detail in 42 CFR section 435.1200, the Federally-Facilitated Marketplace will utilize the same set of eligibility criteria, including selected state-specific options and standard verification procedures. If the state agency chooses the determination model, it must accept the Federally-Facilitated Marketplace determination as final. If the state chooses the assessment model, it must accept findings made by the Federally-Facilitated Marketplace relating to a criterion of eligibility, as long as the Federally-Facilitated Marketplace applies the same policies and verification procedures as those the state agency employs. In a state with a separate CHIP agency, the state Medicaid and CHIP agencies can make different choices allowing the Federally-Facilitated Marketplace to make an assessment or determination. States must choose either the assessment or determination model for all applications; they may not choose between models on a case-by-case basis. States will need to indicate their assessment or determination decision to CMS in a State Plan Amendment, as well as in the Memorandum of Agreement it signs with the Federally-Facilitated Marketplace.

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