Frequently Asked Questions

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. When the state Medicaid program chooses to use a contractor to complete data matches, including matches as required by the Deficit Reduction Act of 2005 (DRA), the program delegates its authority to obtain the desired information from third parties to the contractor.

Third parties should generally treat a request from the contractor as a request from the state Medicaid agency. Third parties may request verification from the state Medicaid agency that the contractor is working on behalf of the agency and the scope of the delegated work.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91226

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. Generally, any TPL administration and performance standards for the MCO will be set by the state and should be accompanied by state oversight.

When TPL responsibilities are delegated to an MCO, third parties are required to treat the MCO as if it were the state Medicaid agency, including:

1. Providing access to third party eligibility and claims data to identify individuals with third party coverage;
2. Adhering to the assignment of rights from the state to the MCO of a Medicaid beneficiary's right to payment by such insurers for health care items or services; and,
3. Refraining from denying payment of claims submitted by the MCO for procedural reasons.

Third parties may request verification from the state Medicaid agency that the MCO or its contractor is working on behalf of the agency and the scope of the delegated work.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91231

Under section 1902(a)(25)(H) of the Social Security Act (the Act) before passage of the Deficit Reduction Act of 2005 (DRA), states were required to have laws in effect that to the extent Medicaid payment was made, the state was considered to have acquired the rights of the Medicaid beneficiary to reimbursement by any other party that was liable for payment. However, payers sometimes deny Medicaid claims based on procedural requirements. Section 1902(a)(25)(I) of the Act, added by the DRA, strengthens the statute by requiring states to enact laws that require health insurers:

1. To accept the state's right of recovery and the assignment to the state of the right of a Medicaid beneficiary or other entity to payment from such party for an item or service for which Medicaid has made payment; and,
2. To process and, if appropriate, pay the claim for reimbursement from Medicaid to the same extent that the plan would have been liable had the plan's card been used for billing at the "point of sale" (POS).

Specifically, the state should pass laws which require an insurer to agree not to deny claims submitted by the state on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation of coverage at the POS that is the basis of the claim.

Whether a plan provision affecting payment for an item or service is solely procedural in nature or whether it defines or limits the covered benefits must be determined on a case-by-case basis.

Note that nothing in the DRA negates the state's responsibility to provide proper documentation when submitting claims to the health insurer so that the insurer can determine that a covered service for which the insurer is liable was provided.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91236

No. States typically do not meet the definition of a covered health care provider under 45 CFR 160.103, and therefore, are not eligible to receive an NPI. If states encounter situations where plans are requiring them to submit an NPI, they can submit a formal complaint to the Office of E-Health Standards and Services (OESS) in CMS by using the online Administrative Simplification Enforcement Tool (ASET). ASET allows individuals or organizations to electronically file a complaint against an entity whose actions they believe violate an Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

States may submit a formal complaint electronically at: https://asett.cms.gov/ASETT_HomePage. ASET users are required to register with OESS and create a user identification name and password. States also may submit a paper complaint. The form is available at: www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Enforcements/Downloads/HIPAANon-PrivacyComplaintForm.pdf.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91241

Section 1902(a)(25)(I) of the Social Security Act requires states to have laws in effect that require health insurers to make payment as long as the claim is submitted by the state within three years from the date on which the item or service was furnished.

Some health insurers currently deny claims submitted by Medicaid if they are not filed within a prescribed time limit, which is applied to plan beneficiaries and providers (e.g., a plan might require beneficiaries and providers to submit claims within 30 days from date of service). If the state Medicaid agency is unable to ascertain the existence of the third party coverage and submit a claim within the time limit, the insurer may attempt to avoid liability.

Any action by the state to enforce its rights with respect to such claim must be commenced within six years of the state's submission of such claim. Health insurers also must respond to any inquiry by a state regarding claims submitted within three years from the date on which the item or service was furnished.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91246

Section 2001(a)(5)(B) of the Affordable Care Act (implemented through regulations for the Medicaid program at section 435.118) increased the minimum income limit applicable to Medicaid eligibility for the mandatory group for poverty-level related children aged 6-18 from 100 to 133 percent of the FPL under section 1902(a)(10)(A)(i)(VII) of the Act. Therefore, if a state is currently covering uninsured children up to 133 percent of the FPL under a separate CHIP, these children must be transitioned to the Medicaid state plan under this children's group effective January 1, 2014. CMS is available to work with states individually on their transition plans for this population.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92606

No. For the purposes of eligibility, these children are considered a mandatory Medicaid group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act. As described below, states will continue to receive the CHIP matching rate for this population.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92611

Yes. Under the Medicaid mandatory group for poverty-level related children under section 1902(a)(10)(A)(i)(VII) of the Act, insured children must be covered in addition to uninsured children (please also see applicable match rate questions below). This is different from the rules governing a separate CHIP program, which preclude coverage for insured children.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92616

No. States continue to have the option to cover children above 133 percent of the FPL either under a Medicaid expansion or separate program. States must maintain CHIP "eligibility standards, methodologies, and procedures" for children that are no more restrictive than those in effect on March 23, 2010 as specified under the "maintenance of effort" provision at 2105(d)(3) of the Act. A parallel requirement in Medicaid can be found at sections 1902(a)(74) and 1902(gg) of the Act. These provisions are effective through September 30, 2019.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92621

Yes. The CHIP enhanced FMAP will continue to be available for children whose income is greater than the Medicaid applicable income level (defined in section 457.301 and based on the 1997 Medicaid income standard for children) after these children transition to Medicaid. This includes children who previously qualified for CHIP in a separate program and uninsured children whose family incomes are up to 133 percent of the Federal poverty level, and therefore will be eligible for Medicaid in 2014. Regular Medicaid matching rates will apply for all other children covered under the mandatory group for children aged 6-18-children with income no more than 100 percent FPL and insured children with income above 100 percent to 133 percent FPL.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92626