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
If a physician presents a certificate for CMS 2370-F eligibility from one of the defined boards, can the certificate be used as the legal document verifying the physician's certification or does the State have to verify with the board that the physician is certified and that the presented certificate is still active and valid?
States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.
FAQ ID:92686
SHARE URLThe 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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ÂFAQ 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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ÂFAQ 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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ÂFAQ ID:92721
SHARE URLWhat help will be available to states to accommodate the added administrative burdens and costs they will have to bear if they expand coverage in Medicaid?
We have provided 90 percent federal matching funds for the new or improved eligibility systems that states are developing to accommodate the new modified adjusted gross income rules and to coordinate coverage with the Exchange. To further reduce system costs, we have promoted ways for states to share elements of their system builds with each other, and we will be sharing the business rules for adopting modified adjusted gross income in the new eligibility systems. In addition we are designing, with extensive state and stakeholder consultation, a new combined and streamlined application that states can adopt (or modify subject to Secretarial approval). And, we will continue exploring opportunities to provide States additional support for the administrative costs of eligibility changes. These and other initiatives relating to state systems development will lower administrative costs.
Implementation of the on-line application system, the new data-based eligibility rules, verification and renewal procedures and states' access to the federally-managed data services hub ("the hub") will collectively help defray states' ongoing costs and result in greater efficiency in the long term. For example, states will be able to electronically verify eligibility factors through the hub, where previously they had to verify through multiple federal venues. This is expected to lower the per-person administrative costs of enrollment and renewal for both newly and currently eligible individuals. As stated in previous guidance, no charge will be imposed on states for use of the hub, nor for the required data accessed there. In addition, it is anticipated that many individuals- both those who are eligible under current state eligibility rules as well as those who are eligible under the adult expansion- will apply for coverage via the Exchange. Our rules provide states the option to have the Exchange determine eligibility for Medicaid or to assess eligibility for Medicaid, in both cases using the state's eligibility rules and subject to certain standards. No charge will be imposed on states for the Medicaid determinations or assessments conducted by the Exchanges.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94586
SHARE URLCMS has released 90/10 funding for states to improve their eligibility systems for Medicaid. Will that funding continue?
Yes. Both the "90/10" funding for Medicaid eligibility (E&E) system design and development, and the enhanced 75 percent matching rate for maintenance and operations of such systems, will be available indefinitely as long as the systems meet applicable program requirements.
In previous guidance (PDF, 104.38 KB), we have assured states that the 90/10 and 75/25 percent funding for eligibility systems will be available without regard to whether a state decides to expand its program to cover newly eligible low-income adults. We reiterate that system modernization will be supported and the enhanced matching funds will be available regardless of a state's decision on expansion. Additionally, we will continue exploring opportunities to provide states additional support for the administrative costs of eligibility changes.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 359.41 KB)
FAQ ID:94591
SHARE URLCMS has advised states that the 90/10 matching funds for modernization of Medicaid eligibility and enrollment (E&E) systems is not related to a state's decision about whether to proceed with the Medicaid expansion for the new adult group. Is 90/10 funding contingent on a state complying with other aspects of the Affordable Care Act related to eligibility? Must a state that uses 90/10 funding build into its design and development support for the new "adult group," even if it does not plan now to proceed with the expansion?
The 90/10 funding is not contingent on a state's decision to proceed with its Medicaid expansion. As the preamble to the final regulation makes clear, the enhanced funding was not solely for eligibility determination systems that support the Medicaid expansion. (76 Fed Reg 21950-21975 (April 19, 2011) and 42 CFR Part 433.
CMS was clear in the final rule that enhanced funding could be available for eligibility determination systems that determine eligibility for traditional eligibility groups. However, such systems must meet all requirements, standards and conditions included in the final rule, including the Standards and Conditions for Medicaid IT that ensure modernized and efficient eligibility systems that produce accurate and timely eligibility determinations and that can interface seamlessly with the Exchange operating in that state. In all states, including those that do not proceed with the expansion, state eligibility systems must be able to electronically pass accounts between the Exchange (whether state-based or federally-facilitated) in order to facilitate seamless coordination. In addition, the systems must be able to support a single streamlined application for coverage among insurance affordability programs, support Modified Adjusted Gross Income (MAGI)-based eligibility determinations; and must support new renewal processes and connections for data-driven, electronic verifications as described in the Medicaid eligibility final rule issued March 23, 2012 (available at http://www.gpo.gov/fdsys/pkg/FR-2012-03- 23/pdf/2012-6560.pdf ).
States are not required to "build in" programming for the new adult group. However, a state that conforms to the Standards and Conditions for Medicaid IT (particularly modular design and separation of business rules from core programming) will be able to quickly and efficiently support enrollment for the expansion population. In addition, enhanced funding is available for states that wish to explicitly "build in" placeholder programming for the new adult group now to provide for future flexibility.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 104.38 KB)
FAQ ID:93216
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