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
If an individual who may already be enrolled in a Medicaid managed care plan, or is eligible to enroll in a Medicaid managed care plan, calls the plan's customer service unit with questions about that plan's Medicaid MCO and/or QHP products, can the Medicaid managed care plan answer consumer questions without violating the Medicaid marketing rules at 42 CFR 438.104?
Yes. Responding to direct questions from consumers is not generally a violation of 42 CFR 438.104. Proactive consumer inquiries to a health plan for information about coverage options, benefits, or provider networks is no different than a consumer obtaining information from the health plan's website. So long as the limits on marketing are satisfied and respected (e.g., the information is accurate and does not mislead, confuse or defraud beneficiaries or the state Medicaid agency), responding to direct questions from potential enrollees with accurate information is not prohibited.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)
FAQ ID:94391
SHARE URLUnder CMS 2370-F, please explain when salaried primary care providers are eligible for the enhanced payment under section 1202 of the Affordable Care Act and whether the employing organization, i.e. a clinic, physician group or hospital, may retain any additional payment received pursuant to this provision.
Generally, the purpose of the 1202 payment increase is to directly benefit physicians performing primary care services. In the instance of salaried physicians, including those working for clinics or other employing organizations that bill on the Medicaid physician fee schedule, this could come in the form of an increased salary. Alternatively, where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.
FAQ ID:91081
SHARE URLUnder CMS 2370-F, are there circumstances in which the enhanced payment under section 1202 of the Affordable Care Act (ACA) will not be paid?
To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.
FAQ ID:91086
SHARE URLUnder CMS 2370-F, if a state uses vaccine product codes to pay for vaccine administration, must it submit a new ACA 1202 state plan amendment (SPA) when those product codes change?
States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.
FAQ ID:91091
SHARE URLUnder CMS 2370-F, must a state submit a new state plan amendment (SPA) if it chooses to provide coverage for a new Current Procedural Terminology (CPT) billing code within the range of E&M codes specified in the law and regulation?
Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.
FAQ ID:91096
SHARE URLWhat federal matching rate will apply for services for which a higher payment is made under CMS 2370-F if the services also qualify for a higher FMAP under the provisions of section 4106 of the Affordable Care Act?
In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular Federal Medical Assistance Percentage (FMAP) rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act are applicable.
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FAQ ID:91076
SHARE URLWhen will states begin making higher payment for Evaluation and Management services reimbursed fee for service under CMS 2370-F?
Effective for dates of service on and after January 1, 2013 through December 31, 2014, states are required by law to reimburse qualified providers at the rate that would be paid for the service (if the service were covered) under Medicare. Most states and the District of Columbia will need to submit a Medicaid state plan amendment (SPA) to increase Medicaid rates up to this level. The Centers for Medicare & Medicaid Services (CMS) has issued a state plan amendment (SPA) preprint for the purpose of expediting review and approval of the primary care payment increase.
For dates of service starting January 1, 2013 qualified providers are entitled to receive the higher payment in accordance with the approved Medicaid state plan amendment. States may not have attestation procedures or higher fee schedule rates in place on January 1, 2013. In that event, providers will likely continue to be reimbursed the 2012 rates for a limited period of time. Once attestation procedures are in place and providers are identified as eligible for higher payment, the state will make one or more supplemental payments to ensure that providers receive payment for the difference between the amount paid and the Medicare rate. Qualified providers should receive the total due to them under the provision in a timely manner.
A state may draw federal financial participation for the higher payments only after the SPA methodology is approved.
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FAQ ID:91271
SHARE URLWhich Medicaid providers qualify for payment under CMS 2370-F? Can physicians qualify solely on the basis of meeting the 60 percent claims threshold, irrespective of specialty designation? Would Board certified "general surgeons" qualify for higher payment if they actually practice as general practitioners?
The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS) the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment. Under the regulation, "general internal medicine" encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA. In order to be eligible for higher payment:
- Physicians must first self-attest to a covered specialty or subspecialty designation.
- As part of that attestation they must specify that they either are Board certified in an eligible specialty or subspecialty and/or that 60 percent of their Medicaid claims for the prior year were for the Evaluation and Management (E&M) codes specified in the regulation. It is quite possible that physicians could qualify on the basis of both Board certification and claims history.
Only physicians who can legitimately self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those specialties recognized by the American Board of Physician Specialties (ABPS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS) qualify.
It is possible that a physician might maintain a particular qualifying Board certification but might actually practice in a different field. A physician who maintains one of the eligible certificates, but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. Similarly, a physician Board certified in a non-eligible specialty (for example, surgery or dermatology) who practices within the community as, for example, a family practitioner could self-attest to a specialty designation of family medicine, internal medicine or pediatric medicine and a supporting 60 percent claims history. In either case, should the validity of that physician's self-attestation be reviewed by the state as part of the annual statistical sample, the physician's payments would be at risk if the agency finds that the attestation was not accurate.
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FAQ ID:91276
SHARE URLThe Affordable Care Act specifies increased payments for three primary care specialties: Family Medicine, General Internal Medicine and Pediatrics. The Final Rule interprets this language to include some subspecialties with a relation to the original three, but does not list the subspecialties. Please identify the subspecialists eligible for higher payment.
Subspecialists that qualify for higher payment are those recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). For purposes of the rule, "General Internal Medicine" encompasses "Internal Medicine" and all recognized subspecialties. The websites of these organizations currently list the following subspecialty certifications within each specialty designation:
ABMS
Family Medicine - Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine.
Internal Medicine - Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine: Transplant Hepatology.
Pediatrics - Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral
Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine.
AOA
Family Physicians - No subspecialties
Internal Medicine - Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology.
Pediatrics - Adolescent and Young Adult Medicine, Neonatology, Pediatric Allergy/immunology, Pediatric Endocrinology, Pediatric Pulmonology.
ABPS
The ABPS does not certify subspecialists. Therefore, eligible certifications are: American Board of Family Medicine Obstetrics; Board of Certification in Family Practice; and Board of Certification in Internal Medicine. There is no Board certification specific to Pediatrics.
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FAQ ID:91281
SHARE URLIs self-attestation required or may a state rely solely on information about Board certification gathered upon provider enrollment or data on a physician's MMIS claims history to determine eligibility for CMS 2370-F?
The rule requires that physicians first self-attest to an eligible specialty or subspecialty and then attest to either Board certification or an appropriate claims history. States cannot pay a physician without evidence of self-attestation.
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FAQ ID:91286
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