Frequently Asked Questions

Yes. A state may elect to delegate the self-attestation process to its contracting health plans under the following circumstances:

1. Each managed care plan has signed documentation on file (provider contract or credentialing application) from the eligible provider attesting to the fact that he or she has a covered specialty or subspecialty designation. This addresses step one of the two-step self-attestation process specified in the rule.
2. The managed care plan has verification of the provider’s appropriate board certification (as part of the credentialing and re-credentialing process). This addresses one option of the second step in the self-attestation process.
3. Should board certification in the eligible specialty not be able to be verified by the managed care plan, the eligible provider must provide a specific attestation to the managed care plan that 60 percent of their Medicaid claims for the prior year were for the Healthcare Common Procedure Coding System (HCPCS) codes specified in the regulation. This addresses a second option for the second step in the self-attestation process.
4.  Such delegation is included in the contract amendment that is otherwise being filed to implement this provision.

• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91456

Generally, the purpose of the 1202 payment increase is to directly benefit physicians performing primary care services. In the instance of salaried physicians, including those working for clinics or other employing organizations that bill on the Medicaid physician fee schedule, this could come in the form of an increased salary. Alternatively, where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.

FAQ ID:91081

To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.

FAQ ID:91086

States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.

FAQ ID:91091

Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.

FAQ ID:91096

Yes, in order to ensure that hospitals comply with the agreement to make presumptive eligibility determinations consistent with state policies and procedures, states have the flexibility to require hospitals to have the staff that will do PE determinations take and pass knowledge tests in order to make PE determinations. Since the PE enrollment process does not require detailed knowledge of Medicaid eligibility policy, the test should be appropriately geared to the information needed to make an appropriate decision and comply with state procedures.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91691

The use of the two performance metrics CMS described in the final rule at section 435.1110 (the proportion of individuals determined PE who submit a full application and the proportion of those who submit an application who are deemed to be Medicaid eligible) is optional for states. States may choose to use other or additional metrics in their hospital PE programs. All states should collect data on hospital performance to fulfill their oversight responsibilities.

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FAQ ID:91696

States are considering a number of different types of performance standards, including the proportion of hospital PE determinations made in an outpatient setting (given that a strong incentive exists for determinations in inpatient settings but it is desirable to also implement PE for outpatients to ensure reaching as broad a population as possible) and the number of hospital PE applications completed in one month. Other states are collecting baseline data in order to measure hospital performance and plan to establish specific standards at a later point.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91701

While individuals may be determined "presumptively eligible" for coverage under the new adult group by a qualified hospital or qualified entity, the newly eligible FMAP is only available once the full eligibility determination has been completed. In these circumstances, the newly eligible FMAP is only authorized with respect to individuals determined eligible for the new adult group by the state agency or other public entity authorized to make final Medicaid eligibility determinations. The regular FMAP applies until such time as the state (or other authorized entity) determines an individual to be eligible for the new adult group and the state confirms that they also meet the definition of a "newly eligible individual."

As noted in our August 2013 FAQs, in appropriate circumstances, a state may retroactively adjust claiming for services provided during a presumptive eligibility period. Specifically, newly eligible status is available based on the effective date of eligibility for the new adult group, which may be as early as the third month prior to the month that the individual applied for Medicaid in accordance with 42 CFR section 435.914 (re-designated at section 435.915 under the March 2012 final eligibility rule), provided that the individual would have been eligible for Medicaid had he or she applied as of the earlier date. To the extent to which the presumptive eligibility period is encompassed within such retroactive eligibility period and the state determines that the individual meets the criteria for newly eligible status, the state may retroactively adjust claiming for services provided during a presumptive eligibility period. The state is not required to make such a retroactive adjustment if the state determines that an adjustment would be administratively burdensome.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91706

There is no recoupment for Medicaid services provided during a PE period resulting from erroneous determinations made by qualified entities. Payment for services covered under the state plan (as well as federal financial participation) is guaranteed during a PE period; without such a guarantee, providers could not rely on the PE determination. As noted, states have various ways to ensure that hospitals are making appropriate PE determinations and must fulfill their oversight responsibilities.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91711