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Frequently Asked Questions

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.

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Under what circumstances can states claim the enhanced 75 percent match for EQR activities?

Under section 438.370, the enhanced match of 75 percent is available for the EQR-related activities described in section 438.358 if all of the following conditions are met:

  • The EQR activity is performed on a managed care organization (MCO) by an entity meeting the requirements of a qualified EQRO in section 438.354 or its subcontractor;
  • The activity is performed pursuant to a contract approved by CMS; and
  • The activity is performed in accordance with a protocol issued by CMS.

FFP at the 50 percent matching rate is available for mandatory and optional EQR-related activities for PIHPs, PAHPs, and affected PCCM entities, regardless of whether the activities were conducted by an EQRO or another entity. FFP at the 50 percent matching rate is also available for EQR and related activities performed for MCOs that are conducted by an entity that is not a qualified EQRO. This is a change from previous regulations, under which the enhanced match was available for EQR of PIHPs to the same extent as MCOs. This provision took effect May 6, 2016.

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FAQ ID:94646

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Will states need to modify already approved contracts to add the final capitation rates to the contract to comply with section 438.3(c), which requires that the payment term be included in the contract?

Yes. We remind states that the requirement that the final capitation rate be specified in the contract is not a new requirement, see section 438.6(c)(2)(ii) of the 2002 final rule. The amount of payment for performance-in this context, the final capitation rate-is a primary component of any contract and must be included for purposes of verifying claims for Federal Financial Participation (FFP) on the CMS-64. In the Final Rule at page 27595, in the context of risk adjustment, CMS suggested that the payment terms under the contract could be identified in an appendix, or additional supporting documentation, to the contract for ease of updating the information when risk adjustment is applied. The state must submit a formal contract amendment when the final capitation rates differ from the payment terms in an approved contract.

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FAQ ID:93171

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Where can I find general information on the change in matching rates for External Quality Review (EQR)?

CMS released an Informational Bulletin (CIB) discussing the change in federal financial participation (FFP) for EQR that was effective May 6, 2016. The CIB includes revised claiming instructions for the CMS-64 and a sample form. It is available at Medicaid.gov on the EQR webpage, under Technical Assistance Documents, and available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib061016.pdf (PDF, 279.08 KB).

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FAQ ID:93471

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Can CMS please clarify if only audited financial statements that are done on a formal Generally Accepted Accounting Principles (GAAP) basis can be used to meet the requirements in section 438.3(m)? Audits can also be done following statutory accounting principles or government auditing standards and it is not clear if states and managed care plans have flexibility in which standard to apply.

The regulation at section 438.3(m) has a general reference to "generally accepted accounting principles" and "generally accepted auditing principles." This means that states have the flexibility to specify the applicable generally accepted accounting and auditing principles for the audited financial reports in the managed care plan contracts. The federal regulation does not endorse a particular standard.

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FAQ ID:93466

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My state is planning for our upcoming EQRO contracting. When does CMS plan to publish a protocol for the new activity relating to the validation of network adequacy?

CMS expects to first issue revised protocols for the current mandatory and optional EQR-related activities in the Fall of 2017. We expect to issue the protocol for the new mandatory EQR activity relating to the validation of network adequacy later in 2017 or early 2018. States will have up to one year from the publication of the protocol to implement the new mandatory EQR activity.

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FAQ ID:94656

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If I have additional questions about EQR and claiming for EQR, who can I ask?

For questions related to state expenditure reporting and claiming instructions for EQR activities, please contact your CMS regional office financial representative. For specific external quality review questions, including what activities qualify for enhanced match, please contact the Division of Quality and Health Outcomes at ManagedCareQualityTA@cms.hhs.gov.

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FAQ ID:94666

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This table indicates what reports are available to CMS Users. These can be found under the "Reports" tab.

Report Name

Description

Available For

Clock Status Report

View the regulatory clock statuses

CPOC, CMS Disapproval Coordinator, SRT Admin CMS Report Admin,

State Agency Profile Report

Overview of a State's Medicaid Plan including the prior 12 months' submission package history

CPOC, CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, CSA, SRT

Submission Detail Report

View details on packages by date

CPOC, CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, SME, PA, PD,SRRVW, SRT

Submission Statistics Detail Report

View all Submission Packages currently in review

CPOC, CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, SME, PA, PD, SRRVW, SRT

Submission Statistics Summary Report

View summary of Submission Packages in a specific review status within a specified date range.

CPOC, CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, SME, PA, PD,SRRVW, SRT

Submission Summary Report

Overview of submitted packages by date

CPOC, CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, SME, PA, PD,SRRVW, SRT

Staff Workload Report

View the number of Submission Packages assigned to each CPOC and SRT member, as of the report run date.

CMS Disapproval Coordinator, SRT Admin, CMS Report Admin, CSA

FAQ ID:92871

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What is the Review Tool Report?

The Review Tool Report is a feature CPOCs, SRTs, Senior Reviewers, Package Approvers, Package Disapprovers, and CMS Report Admins can utilize to see Package Reviewable Units, Reviewers, Reviewable Unit Assessment Values, and Notes.

Log in as CMS Point of Contact or Submission Review Team member. Under the "Records" tab, select "Submission Packages". Then select the link to the submission package. In the left panel, select "Review Tool Report". You may sort the reviews of all Review Team members by Package Reviewable Unit, Reviewer, Reviewable Unit Assessment Value, or Note/Assessments by utilizing the drop-down boxes. You also have the ability to export this report to Excel by selecting "Export to Excel."

FAQ ID:92876

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What is the purpose of each Analyst Note Type?

Analyst Notes are a form of brief internal communication for the CMS Review Team. These notes are a part of the official record; however, State users are not able to see these notes. Analyst Notes are part of the Review Tool for each Reviewable Unit and the SRT or CPOC may view the notes from other Review Team members (depending on the type of note) within the Review Tool, and add his/her own notes.


The CMS Point of Contact or Submission Review Team members may add Analysts Notes through the Review Tool. The types of notes available are referenced in a table below. You will start by logging in as the CMS Point of Contact or Submission Review Team member, then going to the "Records" tab. Under the "Records" tab select "Submission Packages" and then select the link to the package. In the left panel select "Analyst Notes". You will then have the ability to search notes entered by Review Team Members.

Analyst Note Type Description Visible By
Note to self Private note for self only Self
For POC (Formal Review) Indicates information that should be included in disposition CPOC
For Review Team For other Review Team members CPOC and SRT
For RAI Indicates something that requires RAI CPOC and SRT
For Correspondence Log Indicates information that should be communicated to the SPOC CPOC and SRT
Non SRT-User Note on behalf of a CMS participant outside of the Review Team CPOC and SRT
General Note A note that doesn't fall into another category All
Justification Provides bases for a recommended disposition POC Admin, CPOC and SRT
Post-Recommendation Included by other CMS users during the package disposition review POC Admin, CPOC and SRT

FAQ ID:92881

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Certain fields within the reviewable units seem misaligned, how do I fix this issue?

If certain fields are misaligned you may need to adjust your compatibility settings. Click the Tools button in the upper right side of your screen, and then click Compatibility View settings. Next click the Add button. The website is added to your Compatibility View and the screen will realign. You can always remove the website by clicking on the website in the list and clicking the Remove button. If an issue persists, please email the MACPro Help Desk at MACPro_HelpDesk@cms.hhs.gov

FAQ ID:92886

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