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
Will states be eligible to receive the enhanced CHIP FMAP for children who lose Medicaid eligibility due to the elimination of income disregards as a result of the conversion to MAGI under 2101(f)?
Yes. As stated in the Frequently Asked Questions pertaining to this provision posted on April 25, 2013, states may claim the enhanced match available under title XXI for children who lose Medicaid eligibility due to the elimination of income disregards as a result of the conversion to MAGI. These children now meet the definition of a targeted low-income child and will be enrolled in a separate CHIP in accordance with section 2101(f) of the ACA. If states choose the option to maintain Medicaid eligibility for such children title XIX funds and regular FMAP must be used to provide coverage.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)
FAQ ID:91886
SHARE URLAre states allowed to claim enhanced FMAP for enrollees whose family income is above 300 percent of the FPL?
Generally, no. Section 2105(c) (8) of the Social Security Act limits enhanced FMAP to the expenditures associated with children whose effective family income is at or below 300 percent FPL. Expenditures for children whose effective family income exceeds 300 percent of the FPL are matched at the regular Medicaid FMAP rate rather than the enhanced FMAP. However, the enhanced matching rate continues to be available for expenditures on populations whose income exceeds 300% FPL in states in which the income standard exceeds 300 percent as a result of MAGI conversion, as well as for states with approved income limits for CHIP above 300% of the FPL prior to the passage of the Children's Health Insurance Program Reauthorization Act (CHIPRA).
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)
FAQ ID:91891
SHARE URLWill states be allowed to continue to cover parents and receive the enhanced CHIP FMAP for those expenditures?
States are no longer allowed to cover parents in CHIP after Sept. 30, 2013 and therefore, are no longer eligible to receive the enhanced CHIP FMAP for expenditures for parents.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 120.92 KB)
FAQ ID:91896
SHARE URLWhat happens if there is a conflict between information in the flat file and information about the same individual that is already in the state's systems?
As applicant information is entered into state systems, there will be some applicants that will be known to the system, such as people who previously applied to or enrolled in Medicaid, family members of current beneficiaries, and possibly beneficiaries of other human services programs. If, based on this information known to the system, the state finds information that indicates the individual is unlikely to be eligible for Medicaid under MAGI rules, then the state may treat such information as an inconsistency. Just as states are not enrolling applicants on the flat file who have an inconsistency in their income or residency information based on FFM verification without further evaluation, states may also not enroll applicants based on the flat-file data for whom there are discrepancies based on state system information. We will work with states that would like to pursue other options for dealing with information found in state systems when entering individuals from the flat file.
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FAQ ID:91911
SHARE URLWhat if I encounter an account with a long Application_ID or Member_ID?
This issue has been identified to be resolved but the state can proceed to enroll these accounts. The expanded flat file will contain several other fields giving enough information to effectuate enrollment while this issue is resolved. We will work with states that believe they have a problem proceeding to enroll these applicants.
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FAQ ID:91961
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?
What are the new Federal Matching Rates (FMAPs) available under the Affordable Care Act and how do states qualify for them?
Beginning in 2014, the Affordable Care Act authorizes two types of increased federal medical assistance percentages (FMAPs) for state expenditures for low-income individuals in the new adult group (that is, the group described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (the Act)) - the newly eligible FMAP and the expansion state FMAP. Under the statute, these two increased federal matching rates are only available to states that adopt the new adult group.
The newly eligible FMAP is available for medical assistance expenditures on behalf of "newly eligible" individuals, who are defined (in section 1905(y)(2) of the Act) as individuals between the ages of 19 and 64 who are enrolled in the new adult group and who would not have been eligible for full benefits, benchmark coverage (described in subparagraph (A), (B), or (C) of section 1937(b)(1) of the Act), or benchmark-equivalent coverage (described in section 1937(b)(2) of the Act) as of December 1, 2009. An individual may also be "newly eligible" if he or she would have been eligible but could not have been enrolled for such benefits or coverage because the applicable Medicaid waiver or demonstration had limited or capped enrollment as of December 1, 2009.
The newly eligible FMAP (described in section 1905(y)(1) of the Act) is 100 percent in calendar years 2014-2016, 95 percent in calendar year 2017, 94 percent in calendar year 2018, 93 percent in calendar year 2019, and 90 percent in calendar years 2020 and beyond. The expansion state FMAP (described in section 1905(z)(2) of the Act) is an alternate increased FMAP available to match the expenditures for certain adults in states that previously expanded Medicaid and, as a result, may not qualify for the newly eligible FMAP. More details about the expansion state FMAP are included in Question 5. In our August 17, 2011 eligibility NPRM, we proposed that methods for assigning the appropriate FMAP would not require that states undertake the process of using their old eligibility rules to determine if someone would have been eligible under December 2009 rules. We have been consulting with states to test different methodologies for accuracy and simplicity.
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FAQ ID:94071
SHARE URLFor purposes of determining if the newly eligible FMAP applies, how will CMS decide if benefits offered through a section 1115 demonstration meet a benchmark or benchmark equivalent standard?
As described above, the newly eligible FMAP applies to adults in the new low-income adult eligibility group who would not have been eligible for full benefits, benchmark benefits, or benchmark-equivalent benefits under the state's rules as of December 1, 2009. At the time of approval of the section 1115 demonstrations in effect as of that date, neither CMS nor states explicitly designated the coverage offered under demonstrations as "benchmark" or "benchmark-equivalent" coverage, even though the coverage offered to demonstration beneficiaries may have met such standards. Therefore, CMS is requesting that states that used section 1115 demonstrations to expand coverage to low-income adults as of December 1, 2009 provide CMS with an analysis of the benefit package that was offered so that CMS can determine whether the benefits provided could have met a benchmark or benchmark equivalent standard, as in effect in December 2009. A separate analysis should be undertaken for each demonstration benefit package, if different demonstration populations received different benefits under the demonstration.
In conducting the benefit analysis, it will be important for states to utilize a consistent methodology and provide CMS with sufficient data to substantiate their analyses. States' benchmark-equivalence analyses must be certified by a qualified actuary and must include information on the data, assumptions, and methodology used to calculate actuarial values, in accordance with regulations implementing section 1937 of the Act, which are already in effect at 42 C.F.R. 440.330-340. CMS is working with all affected states (that is, states with demonstrations covering adults in effect on December 1, 2009) and will provide them with guidance about the form and manner in which to provide information about eligibility and benefits in effect as of December 1, 2009. CMS will use the benefit analysis that states provide to determine the appropriate FMAP. If any state has questions about this process, they should contact their State Operations and Technical Assistance (SOTA) team representative.
It is also important to note that if the benefit analysis described above indicates that the newly eligible FMAP is not available for a particular population, states may nevertheless be able to claim the expansion state FMAP for certain non-pregnant adults enrolled in the new adult group (as described in Question 5). CMS will work with each state that expanded coverage to adults prior to the enactment of the Affordable Care Act to address questions and to ensure that the correct FMAP is applied to expenditures for each population.
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FAQ ID:94076
SHARE URLWhat is the difference between the expansion state FMAP and the newly eligible FMAP, and which states qualify for the expansion state FMAP?
When Congress enacted the Affordable Care Act, some states had already expanded coverage to adults at higher incomes. The expansion state designation under the statute provides an alternate increased FMAP to states that adopt the new adult group but where some individuals in the new group do not qualify for the newly eligible FMAP because they would have qualified for full benefits, benchmark benefits, or benchmark-equivalent benefits under the state's rules as of December 1, 2009. The expansion state FMAP may be available to qualifying states for expenditures for certain non-pregnant childless adults (those who are enrolled in the new adult group and who the state may require to enroll in benchmark coverage), to the extent that such individuals do not qualify for the newly eligible FMAP.
A qualifying expansion state (described in section 1905(z)(3) of the Act) is a state that, as of March 23, 2010 (the date of enactment of the Affordable Care Act), provided "health benefits coverage" either through Medicaid or a fully state-funded program to parents and nonpregnant childless adults up to at least 100 percent of the Federal Poverty Level (FPL). For purposes of this statutory definition, such health benefits coverage as of March 23, 2010 must have:
- Included inpatient hospital services.
- Not been dependent on access to employer coverage, employer contribution, or employment.
- Not been limited to premium assistance, hospital-only benefits, a high deductible health plan, or a health opportunity account
States seeking to confirm their status as expansion states should provide CMS with an analysis of the scope of coverage provided as of March 23, 2010, citing applicable demonstration special terms and conditions or state-based policies to establish eligibility levels and the coverage provided. As we have explained in a previously released FAQ, if a population covered by a state that qualifies as an expansion state meets the criteria for the newly eligible matching rate, the state will receive the newly eligible matching rate for that population. A state will always receive the more favorable FMAP if two FMAPs might be applicable for a particular population. For example, states that qualify as expansion states may be eligible for the newly eligible FMAP if the expansion offered less than full benefits, benchmark benefits, or benchmark-equivalent benefits, or if the expansion started after December 1, 2009. In such an instance, expenditures for adults in the new adult coverage group will be subject to the newly eligible FMAP. The expansion state FMAP (described in section 1905(z)(2) of the Act) is the regular FMAP rate increased by the number of percentage points equal to a "transition percentage" (which ranges from 50-100 percent) of the gap between the regular Medicaid FMAP and the increased "newly eligible" FMAP. In 2019 and beyond, the expansion state FMAP will be equal to the newly eligible FMAP, which means it will be 93 percent in 2019 and 90 percent in 2020 and thereafter.
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FAQ ID:94081
SHARE URLOur 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
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