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
The final rule for CMS 2370-F indicated that 100 percent Federal Financial Participation (FFP) is not available for stand-alone Children's Health Insurance Program (CHIP) plans. What criteria should be used to determine if a plan is a stand-alone CHIP plan? What agency will determine if a plan is a stand-alone CHIP plan?
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 (PDF, 120.65 KB).
FAQ ID:92696
SHARE URLFederally qualified health centers (FQHCs)/ rural health clinics (RHCs) which receive an encounter rate are excluded under the rule for CMS-2370 F. Are FQHCs/RHCs who are paid provider fee-for-service included in the increase?
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.
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FAQ ID:92701
SHARE URLIn our state, advanced practice nurses must have a collaborative practice agreement with a physician within 50 miles of their office. Under the collaborative practice agreement, a physician must review a certain percentage of the nurse's patient charts every 2 weeks. Such nurses bill independently using their own Medicaid number. Is the collaborative practice agreement enough documentation for an advance practice nurse, with at least 60 percent of services billed by the nurse for calendar year (CY) 2012 for
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.
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FAQ ID:92706
SHARE URLIf the supervising physician does not self-attest to the physician specialty or subspecialty qualification under CMS 2370-F, can the physician supervise a mid-level provider? If the supervising physician self-attests to the 60 percent threshold, but not one of the defined specialty or subspecialty qualifications, can the physician supervise a mid-level?
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.
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FAQ ID:92711
SHARE URLIs it permissible for states with Medicare geographic adjustments that opt to develop rates based on the mean Medicare rate over all counties for each Evaluation & Management code under CMS 2370-F to use a weighted mean based on either the county population or the county Medicaid enrollment?
We believe this would be acceptable. However, the Centers for Medicare & Medicaid Services (CMS) would review the methodology as part of the SPA approval process.
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FAQ ID:92716
SHARE URLIf a state were to proceed with implementation on January 1, 2013, and submit a state plan by March 31, 2013, would the Centers for Medicare & Medicaid Services (CMS) permit the state to claim the enhanced match for services that were reimbursed at the higher rate under CMS 2370-F prior to approval of the state plan?
No. As noted in the final rule, Federal Financial Participation (FFP) in increased rates will not be available until the State Plan Amendment (SPA) is approved.
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FAQ ID:92721
SHARE URLWhich eligibility groups were consolidated under the March 2012 eligibility final rule?
The Medicaid eligibility final rule at 435.110, 435.116 and 435.118 set forth the mechanism for consolidating certain federal eligibility categories into four main groupings: adults, children, pregnant women and parents/caretaker relatives. The table provided below lays out the consolidation of mandatory and optional eligibility groups (a version of this table was also included as part of the preamble to the proposed rule).
Realignment of Medicaid Eligibility Groups
| Before | After Affordable Care Act Final Rule | ||
| Mandatory Medicaid Eligibility Groups (Pre-Affordable Care Act) |
Parents/Caretaker Relatives (section 435.110) |
Pregnant Women (section 435.116) |
Children <19 (section 435.118) |
| Low-Income Families - 1902(a)(10)(A)(i)(I) and 1931 Former AFDC - 435.110 | x | x | x |
|
Qualified Pregnant Women & Children<19 -1902="" a="" 10="" a="" i="" iii="" -="" 435="" 116="" p=""> |
x | x | |
| Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(i)(IV) - No rule | x | x | |
| Poverty-Level Related Children Ages 1-5 - 1902(a)(10)(A)(i)(VI) - No rule | x | ||
| Poverty-Level Related Children Ages 6-18 - 1902(a)(10)(A)(i)(VII) - No rule | x |
| Optional Medicaid Eligibility Groups (Pre-Affordable Care Act) |
Parents/Caretaker Relatives (435.110) |
Pregnant Women (435.116) |
Children <19 (435.118) |
| Families & Children Financially Eligible for AFDC - 1902(a)(10)(A)(ii)(I) - 435.210 | x | ||
| Families & children Who Would be Eligible for AFDC if Not Institutionalized - 1902(a)(10)(A)(ii)(IV) - 435.211 | x | x | |
| Poverty-Level Related Pregnant Women & Infants - 1902(a)(10)(A)(ii)(IX) - No rule | x | x |
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FAQ ID:93131
SHARE URLDo States need to track people enrolled in the adult group who become pregnant?
States are not required to track the pregnant status of women enrolled through the new adult group. Women who enroll in the adult group who later become pregnant will have the option of either staying enrolled in the adult group, or requesting that the State move them to a pregnancy-related eligibility group. This is most likely to occur if women need specific benefits that are not available under the adult group benchmark benefit package.
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FAQ ID:93136
SHARE URLIf a woman indicates on the application she is pregnant, do States need to enroll her as a pregnant woman if she is otherwise eligible for the adult group? Would there be a need to track pregnancy if the benefits for both groups are the same?
If a woman indicates on the application that she is pregnant, she should be enrolled in Medicaid coverage as a pregnant woman. The Affordable Care Act specifies that pregnant women are not eligible for the new adult group. As mentioned above, if a woman enrolled in the adult group later becomes pregnant, she will have the option to stay enrolled in the adult group or request that the State move her to a pregnancy-related eligibility group.
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FAQ ID:93141
SHARE URLIn 2014, will the eligibility groups for people with breast and cervical cancer and disabled workers continue to exist?
Yes, the breast and cervical cancer group and the eligibility group for working disabled individuals will remain optional eligibility groups which States may elect. The Affordable Care Act did not alter the financial or non-financial requirements or methodologies used to determine eligibility for these groups, both of which are exempt from the application of Modified Adjusted Gross Income (MAGI) methodology for determining income.
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FAQ ID:93151
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