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
Under section 4106 of the Affordable Care Act, are clinical preventive services that receive an I or C recommendation ineligible for Medicaid coverage? Are they ineligible for the increased federal financial participation (FFP)?
Clinical preventive services that receive an I or C recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover I or C recommended services. However, United States Preventive Task Force (USPSTF) grade I and C recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.
Supplemental Links:
FAQ ID:91661
SHARE URLUnder section 4106 of the Affordable Care Act, are clinical preventive services that receive a D recommendation ineligible for Medicaid coverage?
Clinical preventive services that receive a D recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover D recommended services. However, United States Preventive Services Task Force (USPSTF) grade D recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.
Supplemental Links:
FAQ ID:91666
SHARE URLWhen will the guidance be available for whether unlicensed practitioners will be able to furnish the Affordable Care Act section 4106 services?
"Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment Final Rule" (CMS-2334-F), published in the Federal Register on 7/15/2013, conformed the regulatory definition of preventive services at § 440.130(c) with the statute relating to the issue of who can be providers of preventive services. Per the final rule, effective 1/1/2014, preventive services may be recommended by a physician or other licensed practitioner. Therefore, unlicensed practitioners will be able to furnish preventive services (including the services mentioned in section 4106), based on the recommendation of a physician or other licensed practitioner, according to the provider qualifications established by each respective state, within broad federal parameters. In order for states to receive the one percentage point federal medical assistance percentage (FMAP) increase for unlicensed practitioners, it is likely that a state plan amendment updating section (13)(c) of the state plan will be necessary. Please refer to the preventive service CMCS Informational Bulletin issued on November 27, 2013 for additional information regarding adding unlicensed practitioners to the preventive services section of the state plan.
Supplemental Links:
FAQ ID:91676
SHARE URLUnder section 4106 of the Affordable Care Act, can CMS recommend a list of current procedural terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes to be covered for the corresponding United States Preventive Services Task Force (USPSTF) grade A and B recommendations?
While section 4106 of the Affordable Care Act states that USPSTF grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration must be covered to secure the one percentage point FMAP increase, it is incumbent upon state Medicaid agencies to continue to work with, and communicate to, providers concerning state-specific systems and appropriate codes. The information provided by the American Medical Association in the below link (the CPT Code Pocket Guide: Preventive services with cost-sharing waived) can be used as a starting point in creating a cross-walk from the USPSTF and ACIP recommended codes, but it is not all-inclusive.
In addition, the October 2012 State Health Official (SHO) letter, gave the below web site address for HCPCS codes effective for service dates on or after January 1, 2012, and contacts within CMS for questions regarding HCPCS codes.
http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
Supplemental Links:
FAQ ID:91686
SHARE URLIs there a deadline for states to create a public awareness campaign under section 4004(i) of the Affordable Care Act?
While there is no deadline given in the provision for states to create public awareness campaigns to inform Medicaid beneficiaries of the preventive services covered in their state, CMS looks forward to partnering with states to develop innovative approaches. CMS is required to prepare a periodic Report to Congress including "summaries of the states' efforts to increase awareness of coverage of obesity-related services," and the next report will be submitted by January 1, 2014. As such, CMS is gathering information about states' efforts to inform the 2014 report. States may email MedicaidCHIPPrevention@cms.hhs.gov to submit information about preventive and obesity-related services public awareness efforts in their communities.
Supplemental Links:
FAQ ID:91491
SHARE URLCan a state submit a state plan amendment (SPA) to implement section 4106 of the Affordable Care Act at any time?
Yes, a state may submit a SPA at any time. The one percentage point increase in federal medical assistance percentage (FMAP) per the requirements outlined in section 4106 of the Affordable Care Act does not have an end date.
Supplemental Links:
FAQ ID:91511
SHARE URLCan states rely on the information contained in the enhanced flat files?
We believe these files have information that states can rely on. As with any transmission of data or logic process, discrepancies may arise. However, we have done quality reviews and continue to act on reports of issues as quickly as possible by investigating them and introducing systems fixes as needed. We are continuing our testing and quality assurance efforts as well. We expect that states will be doing the same on accounts transferred from states to the FFM. We will continue to rely on our daily desk officer calls and our SOTA process to follow up with states on any questions that may arise.
Supplemental Links:
FAQ ID:91906
SHARE URLWhat action may the state take if the state believes there is another basis for excluding an individual from flat file-based enrollment based on state analysis or external information?
If the state would like to exclude individuals from enrollment based on the flat file, please reach out to CMCS to discuss the state's options. Our goal in offering this flat file option is to provide an additional avenue for enrollment and we will work with states on how they might best maximize the use of these files.
Supplemental Links:
FAQ ID:91921
SHARE URLWhat if a state later determines that a person enrolled based on information in the flat file is not eligible for Medicaid or CHIP?
In a letter dated November 29, 2013, (see http://www.medicaid.gov/Federal-PolicyGuidance/downloads/SHO-13-008.pdf (PDF, 117.76 KB)) CMS offered states the opportunity to apply for a waiver under section 1902(e)(14)(A) of the Social Security Act to allow them to make temporary enrollment decisions based on the information included in the flat file. So, as long as states follow the procedures outlined in the guidance and other applicable rules with respect to eligibility and claiming, federal funding is available for this temporary enrollment. Individual's circumstances might change and other factors might arise that could change the outcome of the eligibility determination once the state evaluates eligibility based on the full account transfer. Federal funding is not at risk for states that follow appropriate procedures to enroll beneficiaries based on the FFM's determination or assessment of eligibility.
Supplemental Links:
FAQ ID:91926
SHARE URLWe understand that if we use the expanded flat file for enrollment, applicants are eligible to receive Medicaid for 90 days for assessment states and that we will run them through a MAGI-based determination in the future. If we enroll someone based on the flat file, and then become aware of additional information regarding the individual's eligibility before we receive the full account transfer, do we need to act on that information?
Since the waiver is a temporary grant of authority, if changes in circumstance are reported then states have the flexibility to choose to act on reported changes immediately or wait until the full determination occurs. If a state has the capability to review and process the changes reported they can do so, and if a state does not wish to act upon reported changes during this temporary waiver period that is also permissible. States should discuss with CMS how to document the state's policy regarding changes in circumstance in the waiver request.
Supplemental Links:
FAQ ID:91931
SHARE URL