CO-19-0033
Reimbursement update for Pharmacy Reimbursement Rate
WA-20-0011
Makes changes to the 1915(k) Community First Choice state plan option to include changes related to Washington's response to the COVID-19 outbreak.
What federal match rate is available to the states for administrative costs incurred from implementation of the CMS 2370-F rule?
The regular administrative federal match rate is applicable to administrative costs associated with implementation of this rule. Section 1905(dd) of the Social Security Act (the Act) authorizes increased Federal Medical Assistance Percentage (FMAP) only for eligible services provided by eligible providers pursuant to section 1902(a)(13)(C) of the Act
Is the relevant Medicare rate both the 'floor' and 'ceiling' for health plan payments to eligible providers for eligible services under CMS 2370-F?
The applicable Medicare rate does effectively become the "floor" for payments to eligible providers for eligible services, but not the "ceiling." Health plans may pay above that rate depending on their specific contractual arrangements with providers.
Are bonus payments and other incentive arrangements for health plans included in the CMS 2370-F
We addressed the treatment of bonus payments and other incentive arrangements in terms of identifying the 2009 base rate in the final rule and take this opportunity to clarify that such arrangements are similarly excluded from the methodology for determining the rate differential.
Will Medicaid health plans be required to pay eligible providers the higher rate prior to receiving payment from the State for the higher rate?
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.
May providers self-attest through the use of a claims modifier to qualify for CMS 2370-F?
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.
Can a state review providers whose claims meet the 60 percent threshold and assume that those providers would be automatically eligible?
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.
CMS clarified in the final rule for CMS 2370-F that, for out of state providers,
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.
With respect to the use of board certification to confirm a physician's self-attestation for CMS
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.