Does the 60 percent threshold in CMS 2370-F include both Evaluation and Management (E&M) codes and vaccine administration codes?
Yes. The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes.
Is self-attestation required or may a state rely solely on information about Board certification gathered
The rule requires that physicians first self-attest to an eligible specialty or subspecialty and then attest to either Board certification or an appropriate claims history. States cannot pay a physician without evidence of self-attestation.
What federal matching rate will apply for services for which a higher payment is made
In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act.
How do states implement hospital PE?
States have flexibility in establishing agreements with hospitals, structuring training programs and conducting oversight consistent with overall federal guidance and the goal of ensuring that hospital PE is available as a way for individuals to access coverage. Under the regulations, states must explain their PE policies and procedures to their qualified entities.
IL-20-0003
Proposes a $4,375,000 increase to provide coverage of hospital services provided due to a lack of appropriate placement
CA-20-0001
Adds a new reimbursement methodology for the Drug Medi-Cal Organized Delivery System (DMC-ODS) Substance Use Disorder (SUD) services
KS-19-0019
Proposes to allow the state to comply with the Medicaid Drug Utilization Review (DUR)
provisions included in Section 1004 of the Substance Use-Disorder Prevention that promotes
Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271).
provisions included in Section 1004 of the Substance Use-Disorder Prevention that promotes
Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271).
Does a health plan's submission of information from its full eligibility file, for the purpose
State laws determine what information is required of the health plans. A health plan's disclosure and use of information that is required to be submitted under state law - such as, information from insurer eligibility files sufficient to determine during what period any individual may be, or have been, covered by a health insurer and the nature of the coverage that is or was provided by the health insurer — is consistent with the HIPAA privacy provisions.
May state Medicaid agencies use contractors to complete data matches with health insurers?
Yes. State Medicaid programs may enter into data matching agreements directly with third parties or may obtain the services of a contractor to complete the required matches. Such arrangements should comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA)'s "Business Associate" requirements, where applicable.
Can Medicaid Managed Care Organizations (MCOs) use a contractor to complete data matches with health insurers, as authorized by the state Medicaid agency?
Yes. State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs to perform third party liability TPL discovery and recovery activities, including data matches as required by the Deficit Reduction Act of 2005 (DRA). The Medicaid program may authorize the MCO to use a contractor to complete these activities. The contract language between the state Medicaid agency and the MCO dictates the terms and conditions under which the MCO assumes TPL responsibility.