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
Does the May 6, 2016 effective date for the change in FFP for EQR-related activities apply based on the date of approval of the EQRO contract, the date the activity was performed, or the date of expenditure for the EQR activity?
Regardless of whether an EQRO contract is approved before or after May 6, 2016, the change in FFP for EQR-related activities was effective May 6, 2016 for expenditures incurred by the state on or after May 6, 2016. Per general CMS-64 claiming principles, a state incurs an expenditure that may be claimed on the CMS-64 on the date the state pays the EQRO for the completed performance of the contracted EQR-associated activity.
The change to the FFP match rate for expenditure reporting takes effect in the middle of a quarter, which means that states must ensure that claims for expenditures for EQR activities affected by the change in FFP which were paid before May 6th and claims for expenditures which were paid on or after May 6th are reported separately. For only the quarter ending June 30, 2016, the CMS-64 EQRO Line 17 will allow states to report state expenditures associated with PIHP EQRO activities paid prior to May 6, 2016 and claim the enhanced 75 percent match. State expenditures associated with PIHP EQRO activities paid on or after May 6th must be claimed at the 50 percent matching rate.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:94651
SHARE URLUnder 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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:94646
SHARE URLWill 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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:93171
SHARE URLWhere 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).
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:93471
SHARE URLCan 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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:93466
SHARE URLMy 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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:94656
SHARE URLIf 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.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)
FAQ ID:94666
SHARE URLHow should states account for the cost of the Health Insurance Providers Fee in their actuarially sound capitation rates?
States and their actuaries have flexibility in incorporating the Health Insurance Providers Fee into the state's managed care capitation rates. This fee is not unlike other taxes and fees that actuaries regularly reflect in developing capitation rates as part of the nonbenefit portion of the rate. CMS believes that the Health Insurance Providers Fee is therefore a reasonable business cost to health plans that is appropriate for consideration as part of the non-benefit component of the rate, just as are other taxes and fees.
Supplemental Links:
FAQ ID:91126
SHARE URLWhat methodologies are acceptable to account for the Health Insurance Providers Fee in capitation rates? Can states make retroactive adjustments to the capitation rates once the actual assessments on the health plans are known?
States have the flexibility to account for the Health Insurance Providers Fee on a prospective or retroactive basis. In the event that a prospective calculation results in a capitation rate that is too high or too low, the capitation rate may be adjusted after the actual tax assessment is known. States may also account for the fee prospectively by withholding such amounts until the health plan's actual fee is known. The capitation payment, net the amount of the withhold, must remain actuarially sound and the state can only claim Federal Financial Participation (FFP) on the actual expenditures paid from the withhold to reimburse the health plans for the fee.
States may account for the Health Insurance Providers Fee as an aggregated retroactive adjustment to the rates for the contract year once a health plan's liability is known. CMS anticipates that states would move to a prospective calculation as states and health plans obtain more experience with the fee.
Supplemental Links:
FAQ ID:91141
SHARE URLCan the Health Insurance Providers Fee be paid to health plans as a separate payment after the plans' fee liability is known?
No. There is no Federal Financial Participation (FFP) available for Health Insurance Providers Fee payments made outside of actuarially sound capitation rates, per the requirements of section 1903(m)(2)(A(iii) of the Social Security Act and implementing regulations at 42 CFR 438.6(c)(2). Therefore, any payment for the fee-whether on a prospective or retrospective basis-must be incorporated in the health plan capitation rates and reflected in the payment term under the contract.
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FAQ ID:91151
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