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
What are the security requirements for receiving and acting upon the expanded flat file? Can we follow processes consistent with paper applications (logging starts once the information is entered into the eligibility system)?
Yes, all the regulations and security constraints that apply to paper applications are necessary with the expanded flat file. The state would need to maintain the same level of security for the expanded flat file as they would in regard to paper applications.
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FAQ ID:91941
SHARE URLWhat if an account contains an out of state address?
Applicants can apply for whatever state they choose. Sometimes someone will want to file an application for a state they don't currently live in. For example, if they are temporarily residing outside the state or have a family member or tax dependent that needs coverage who lives there. When an applicant applies on the Federally Facilitated Marketplace (FFM), they provide their home address and that information is used to validate the eligibility criteria of state residency during the eligibility determination process. If an applicant does not indicate they have a home address in the state they are applying to, and they do not indicate they are temporarily absent from the state, they will be denied Medicaid, CHIP and APTC for that state in accordance with state and federal rules. However, an applicant can always request a full determination, and in doing so, the account is transferred to the state indicated. In order to respond, the state will need to verify residency, and approve or deny Medicaid as applicable.
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FAQ ID:91946
SHARE URLWhat if there is an account for someone who is already enrolled in Medicaid?
The flat file contains only accounts that have been determined/assessed as eligible for Medicaid or referred for a full determination at the applicant's request. If an individual applies at the FFM, is potentially eligible for Medicaid based on income, and does not indicate that he or she is currently enrolled in Medicaid, the FFM does not check for other coverage. The state would do a check with its system as they do when an applicant applies directly to the state and take appropriate action if the person is already enrolled.
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FAQ ID:91951
SHARE URLWill the Federally-Facilitated Marketplace apply Medicaid policies and verification procedures differently under the "assessment" and "determination" models?
In an assessment model, the Federally-Facilitated Marketplace will not make a final Medicaid determination. Instead, the Federally-Facilitated Marketplace will transmit the account to the Medicaid or CHIP agency when they have evaluated the individual and identified him or her as Medicaid or CHIP eligible, and the Medicaid or CHIP agency will make the formal determination. In a determination model, the Medicaid or CHIP agency delegate the authority to make determinations to the Federally-Facilitated Marketplace. In both an assessment and determination model, as described in more detail in 42 CFR section 435.1200, the Federally-Facilitated Marketplace will utilize the same set of eligibility criteria, including selected state-specific options and standard verification procedures. If the state agency chooses the determination model, it must accept the Federally-Facilitated Marketplace determination as final. If the state chooses the assessment model, it must accept findings made by the Federally-Facilitated Marketplace relating to a criterion of eligibility, as long as the Federally-Facilitated Marketplace applies the same policies and verification procedures as those the state agency employs. In a state with a separate CHIP agency, the state Medicaid and CHIP agencies can make different choices allowing the Federally-Facilitated Marketplace to make an assessment or determination. States must choose either the assessment or determination model for all applications; they may not choose between models on a case-by-case basis. States will need to indicate their assessment or determination decision to CMS in a State Plan Amendment, as well as in the Memorandum of Agreement it signs with the Federally-Facilitated Marketplace.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93731
SHARE URLIn an assessment model, an applicant may be assessed eligible by the Federally-Facilitated Marketplace and later receive a determination as ineligible by the state Medicaid/CHIP agency. Does the state Medicaid agency need to communicate the eligibility finding to the Federally-Facilitated Marketplace?
Yes. In an assessment model, where an applicant is assessed eligible by the Federally-Facilitated Marketplace and later found to be ineligible by the state Medicaid agency, the state must transfer the account to the Federally-Facilitated Marketplace. Once received, the state Medicaid determination will be accepted and the account will be assessed by the Federally-Facilitated Marketplace for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits/Cost Sharing Reductions.
For the determination model, as discussed in section 435.1200(c), as governed by the agreement signed between the Medicaid agency and the Federally-Facilitated Marketplace, the Federally-Facilitated Marketplace determines eligibility for individuals applying to the Federally-Facilitated Marketplace for Medicaid/CHIP based on MAGI, and the state Medicaid or CHIP agency agrees to accept eligibility findings made by the Federally-Facilitated Marketplace.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93736
SHARE URLIn an assessment model, if an applicant applied via the Federally-Facilitated Marketplace and is found eligible for Medicaid or CHIP, how will the Federally-Facilitated Marketplace coordinate with the state Medicaid or CHIP agency regarding eligibility, enrollment, redeterminations, or renewals for Medicaid/CHIP?
For individuals assessed eligible for Medicaid/CHIP by the Federally-Facilitated Marketplace, their account will be transferred to the state Medicaid/CHIP agency for a final determination. Once enrolled in Medicaid/CHIP, regardless of where the initial application was submitted, all updates, redeterminations and renewals are handled by the enrolling entity (e.g., the state Medicaid/CHIP agency). No further coordination would be needed with the Federally-Facilitated Marketplace except when an individual is found ineligible for Medicaid or CHIP during the redetermination process. In this case, the state agency would transfer the individual's account to the Federally-Facilitated Marketplace to be assessed for enrollment in a qualified health plan (QHP) and eligibility for Advanced Premium Tax Credits /Cost Sharing Reductions. The Federally-Facilitated Marketplace will not handle redeterminations or renewals for Medicaid/CHIP and will refer individuals to the appropriate site in the state as appropriate.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93741
SHARE URLWill the Federally-Facilitated Marketplace integrate its enrollment file with the state's client registry so that data for households participating in both state programs and the Marketplace can be synchronized? Will the Federally-Facilitated Marketplace routinely check the Medicaid/CHIP enrollment files to determine any overlap between the Federally-Facilitated Marketplace and Medicaid/CHIP enrollment logs?
No. There will not be integration of the Federally-Facilitated Marketplace and states' client registries. Instead, the Federally-Facilitated Marketplace will both verify current Medicaid/CHIP enrollment as part of the Federally-Facilitated Marketplace "applicant" application, and will also conduct quarterly checks of the Medicaid/CHIP enrollment files to determine any overlap with Federally-Facilitated Marketplace enrollment logs.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93746
SHARE URLFor physicians in neighboring states, can we require them to self-attest under CMS 2370-F using our state's protocol, rather than relying on the determination made by the home state's Medicaid program?
Our understanding of the CMS 2370-F rule is that advanced practice clinicians are eligible for the increased payment as long as they are working under the personal supervision of an eligible physician; eligible meaning the supervising physician is also eligible for the increased payment.We are trying to determine if: 1) advanced practice clinicians also can attest that they are working under the personal supervision of an eligible physician at the time of attestation, or 2) if they have to indicate who the supervising physician is on each claim for an eligible service and then we would need to see if that physician is eligible for the increased payment at the time of claim processing.If advanced practice clinicians are billing under their own provider numbers, how can we know that they're under the personal supervision of an eligible physician?
The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.
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FAQ ID:94101
SHARE URLAre Indian Health Services (IHS) excluded from the increased provider payments under CMS 2370-F? Is there any change in FMAP under CMS 2370-F for primary care services delivered through IHS?
IHS and tribal facilities are often not separately paid for physician services, but instead receive an all-inclusive rate for inpatient or outpatient service encounters. To the extent that a particular claim is made for primary care services furnished by an eligible physician, there is no exclusion from the requirement for provider payment at least equal to the Medicare Part B fee schedule rate. States would continue to receive Federal Medical Assistance Percentage (FMAP) at the 100 percent rate for services received through IHS and tribal facilities and reimbursed through the all-inclusive rate. For other physician services, including Medicaid payments for contract health services, states would receive the regular FMAP for the base payment, and 100 percent for the difference between the state plan rate in effect on July 1, 2009 and the applicable 2013 and 2014 Medicare rates.
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FAQ ID:94106
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