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
Yes. While coverage of children protected by 2101(f) is mandated through a separate CHIP, states may instead continue to provide coverage of these children in the state's Medicaid program, thereby eliminating the need to provide coverage in a separate CHIP in accordance with section 2101(f).
If a state chooses this option, children in the state would not lose Medicaid eligibility due to the elimination of disregards under the new "modified adjusted gross income" (MAGI) based methodologies. A Medicaid SPA could cover such children as an optional reasonable classification of children under 42 CFR section 435.222, with a disregard of all income (so that there would be no required determination of income).
The state will need to accurately identify the population of children who otherwise would lose Medicaid eligibility effective January 1, 2014 due to the elimination of income disregards as the new optional reasonable classification of children covered under this group. Children covered under this classification would remain categorically eligible based on their enrollment in Medicaid on December 31, 2013.
In order to limit the protection afforded under this strategy to the same timeframe as the protection which otherwise would be afforded to each affected child under a separate CHIP, the state may define this group as "children who would lose Medicaid eligibility on the initial redetermination of income using MAGI-based income determination due to the elimination of income disregards." The classification would thus not include individuals whose income is being redetermined after that time. This would be parallel to the treatment of this population in a separate CHIP, as automatically eligible in CHIP only when initially losing Medicaid eligibility.
For SPA page S52 for optional reasonable classifications of children that will be submitted for Medicaid state plan eligibility in 2014, the state should enter information for this new reasonable classification of children, just like it will enter information for any other reasonable classification covered by the state. The state would define this reasonable classification using the approved state plan language and would enter that no income test is used for this classification because there was no income test (i.e., all income was disregarded) in 2013.
In addition, once the Medicaid SPA has been approved, interested states should also submit a CHIP SPA (CS14) and check the first option indicating that: "The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision."
A state interested in covering children protected by section 2101(f) of the ACA should indicate its interest to CMS on its next State Operations and Technical Assistance (SOTA) call.
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No. The 75%/25% matching rate for eligibility systems is limited by the statute to activities directly related to an eligibility determination. A level of care assessment is not directly related to the eligibility determination. Although the assessment itself is not eligible for the 75% match, the entry of the level of care result into the eligibility system may be matched at 75%.
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No. A disability determination is not directly related to the eligibility determination, even though the outcome of that determination may be used to identify the appropriate eligibility group, financial methodology and the benefits that will be available to the individual. The eligibility group, financial methodology and benefits are based on the state plan, not on the eligibility system. Although the disability determination itself is not eligible for the 75% match, the entry of the disability information into the eligibility system may be matched at 75%. This analysis is based on the SMM Sec. 11276.7 B, which discusses prior authorization and claims processing. The prior authorization itself is not eligible for the 75% match, however the program decision, based on that prior authorization, to pay or not pay a claim that is pending in the system is eligible for the 75% match.
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Individuals who assist applicants by facilitating their applications, who perform outreach activities, or who enter application data on behalf of the applicant are not eligible for the 75% match. Only individuals who are authorized by the single state agency to enter data other than application elements into the eligibility system, who have responsibility for evaluating data in order to make an eligibility determination, who are authorized to exercise discretion in the evaluation of data, who are authorized to make an eligibility determination and who are accountable to the single state agency for such determinations are eligible the 75% match for those activities. This includes eligibility workers, whether in house or out-stationed, as long as there is a formal, written agreement with the single state agency that authorizes their eligibility activities and specifies direct lines of accountability to the single state agency. Both intake workers and on-going eligibility workers who meet these requirements may be claimed at 75%, based on appropriate cost allocations.
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Section 4004(i) requires the Department of Health and Human Services (HHS) to provide guidance to states and health care providers regarding preventive and obesity-related services that are available to Medicaid enrollees, including obesity screening and counseling for children and adults.
It also requires states to design public awareness campaigns to educate Medicaid enrollees regarding the availability and coverage of preventive and obesity-related services, with the goal of reducing incidences of obesity.
Lastly, it requires HHS to submit a Report to Congress every three years, beginning on January 1, 2011, which addresses the status and effectiveness of the activities above, including summaries of state efforts to increase awareness of coverage of obesity-related services. The 2014 report can be found at: https://www.medicaid.gov/sites/default/files/medicaid/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf.
Ways CMS helps states meet these requirements include the following:
- CMS hosts a series of calls and webinars to support state efforts to inform Medicaid enrollees regarding coverage of preventive services. These calls provide an opportunity for states to share and learn about best practices for education and outreach campaigns, obesity-prevention initiatives, and other Medicaid and CHIP disease prevention activities.
- CMS develops fact sheets that address Medicaid coverage of preventive and obesity-related services, which states can personalize and share with providers and other stakeholders.
- CMS collects and disseminates examples of state Medicaid program efforts to increase awareness of preventive services.
- Additional written resources are published on the Prevention page on the Medicaid.gov website: https://www.medicaid.gov/medicaid/benefits/prevention/index.html
- Technical assistance questions can be sent to: MedicaidCHIPPrevention@cms.hhs.gov
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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.