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
While some plans may be able to pay the higher rate prior to receiving state funds, the final rule does not obligate a health plan to pay eligible providers the higher rate until they have been provided the funds to do so.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94251
The State will issue a communication instructing providers that only those who are board-certified in a specified specialty/subspecialty or who meet the 60 percent threshold of appropriate claims history are eligible to receive the rate increase.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94271
Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 94276
As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 94361
The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 94376
The certification must be current. If it has lapsed but the physician still practices as an eligible specialist the self-attestation would need to be supported with a 60 percent claims history.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
FAQ ID: 94296
The Center for Medicare & Medicaid Services (CMS) approves CHIP programs as stand-alone or Medicaid expansions. Information on whether or not a particular state operates a stand-alone or expansion program is available at http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Downloads/Map-CHIP-Program-Designs-by-State-.pdf.
Date: January 27, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Autism
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 92696
FQHCs and RHCs are required by law to be paid at least prospective payment system (PPS) for core primary care services. Physician services are core FQHC and RHC services and, therefore, should not be reimbursed on a fee-for-service basis.
Supplemental Links:
Date: January 27, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 92701
Increased payment is available for services provided by eligible physicians or for services provided under their personal supervision. This means that the physician accepts professional responsibility (and legal liability) for the services provided. It does not appear that the collaborative arrangement requires that the physician accept professional responsibility for each of the services provided by the nurses. Therefore, increased payment would not be available.
However, if the physician is required to accept professional responsibility for the services provided by the advanced practice nurses and the physician is eligible based on self-attestation to a specified primary care specialty designation supported by either appropriate Board certification or a 60 percent claims history, then increased payment would be available.
Supplemental Links:
Date: January 27, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 92706
The eligibility of services provided by mid-level/non-physician practitioners is dependent on 1) the eligibility of the physician and 2) whether or not the physician accepts professional responsibility for the services provided by the mid-level. As previously noted, physicians are eligible only if they first self-attest to a specified specialty designation and also to either being appropriately Board certified or having a 60 percent claims history.
Supplemental Links:
Date: January 27, 2013
Topics:
Affordable Care Act
Medicaid and CHIP Program (MACPro)
Subtopics:
Final Rule
Medicaid Expansion
Primary Care Services
FAQ ID: 92711