For Medicaid eligible children, the state does not reimburse for the immunizations due to the
Section 1905(a)(13)(B) of the Act is limited to adult vaccines, therefore, the following applies:
Section 4106 of the Affordable Care Act states that "any medical or remedial services [designed]
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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While section 4106 of the Affordable Care Act authorizes a 1% federal medical assistance percentage
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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Under section 4106 of the Affordable Care Act, if a state elects to cover preventive
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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Is there a state plan amendment (SPA) pre-print the states can use to comply with section 4106 of the Affordable Care Act or is CMS planning to issue one?
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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Under section 4106 of the Affordable Care Act, the list of United States Preventive Services
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.
Are fluoride treatments (also known as fluoride varnishes) eligible for the one percentage point increase
No, fluoride varnish is not eligible for the one percentage point FMAP increase. In the future, if the United States Preventive Services Task Force (USPSTF) adds fluoride varnish to the A or B recommended preventive services, states will be required to cover the fluoride varnish with no cost-sharing.
According to the United States Preventive Services Task Force (USPSTF) methodology "The Task Force also
Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 159.52 KB)
Does a state that has both a fee-for-service (FFS) and a managed care delivery system,
A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit.
Under what portion of the state plan should the state add the Affordable Care Act section 4106 information?
The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.
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