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
How were the new MAGI-based income standards set?
Based on guidance issued in December 2012 (PDF, 177.59 KB), CMS worked with states to set their new standards. Most states used a model that determines the average value of the disregards a state had in place and then added that amount to the old standard to create the new eligibility levels. In the example above, in a state with a net income standard of 100% of the FPL, if the average value of the disregards equaled 6 percentage points of the FPL, that value would be added to the old standard for a new eligibility standard of 106% of the FPL.
FAQ ID:92496
SHARE URLWith respect to MAGI conversion, how will the 5% disregard be applied?
The Affordable Care Act established an income disregard equal to five percentage points of the FPL disregard "for the purposes of determining income eligibility" for individuals whose eligibility is based on MAGI. In our final rule issued July 15, 2013, we provide that the disregard is applied to the income calculation of individuals only to the extent that the disregard matters for the purposes of determining eligibility for Medicaid or CHIP under MAGI-based rules-that is, those for whom the application of the disregard means the difference between being eligible for Medicaid or CHIP and being ineligible.
The disregard matters for purposes of determining Medicaid or CHIP eligibility only in cases where individuals have MAGI-based income that is above the highest applicable income standard under the program (Medicaid or CHIP), but would be within that income standard if the disregard were applied. This is the case only when the MAGI-based income is no higher than five percent of the FPL higher than that income standard. The disregard would not be applied for a determination of the particular eligibility group in which the individual qualifies, but only for overall eligibility for Medicaid or CHIP. We understand that this policy changes how disregards have been applied in the past, but believe this policy should be administratively simple to apply, for example, by applying the disregard at the point before a decision of ineligibility based on income would otherwise be made. This also ensures that the disregard does not reduce the "newly eligible" population for whom the increased federal matching rate is available.
For example, in a state that extends coverage to the new adult group, if a parent applied and has MAGI-based income within five percentage points of the FPL above the net income standard for the mandatory parent/caretaker relative group, the disregard would not apply because the disregard would not be needed for eligibility. The parent could be made eligible in the adult group instead. In that same state, if a parent applied with MAGI income within five percentage points of the FPL above the net income standard for the adult group (133% FPL), the five percent disregard would be applied to ensure that the parent could obtain eligibility in Medicaid and the parent would be made eligible in the adult group.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)
FAQ ID:92591
SHARE URLUnder CMS 2370-F, may practice managers or billing staff of large group practices and health systems attest on behalf of their physicians on the basis of information on board certification in the records of the practice or health system?
If these practices and health systems maintain the types of documentation described in the previous answer, FAQ45736, with respect to managed care organizations, attestation by the group or system would be acceptable. As previously noted, a physician actually must be practicing as an internist, pediatrician or family physician in order to be eligible for higher payment. Board certification does not always equate to practice characteristics. Therefore, attestation on the basis of information on board certification alone would not suffice.
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FAQ ID:93866
SHARE URLUnder CMS 2370-F, if a physician renders services in both the managed care and fee for service environments, must he or she self-attest to eligibility twice?
No. The attestation and eligibility are physician-specific. If a physician provides services both in a fee-for-service and managed care environment, they need only complete the process of attestation once in order to receive higher payment for all eligible services they provide. CMS expects all information on self-attestation to be fully available to the state, regardless of which party collected this information.
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FAQ ID:93871
SHARE URLUnder CMS 2370, may physicians who practice in two (or more) states meet the 60 percent threshold based on all services provided in all states, or must they qualify on the basis of the services they provide in each state?
States have the flexibility to count eligible services provided by a physician in neighboring states in meeting the 60 percent threshold, but are not required to do so.
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FAQ ID:93876
SHARE URLThere are at least two current procedural terminology (CPT) codes (99429 and 99499) for which there are no relative value units (RVU) and the state manually prices the services for purposes of Medicaid payment. Will CMS develop a Medicare-like rate for these codes under the CMS 2370-F rule?
These services would not be subject to the minimum payment standard set in the rule because there are no RVUs and there is no conversion factor associated with them. Therefore, a Medicare-like rate cannot be developed. The state may continue to reimburse them at the current Medicaid rate but enhanced federal financial participation (FFP) will not be available for those services.
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FAQ ID:93881
SHARE URLUnder CMS 2370-F, if a physician self-attests to being a primary care provider and supports that attestation with evidence of appropriate board certification, must we review that physician's practice to verify that they actually practice in that manner?
No. Verification of current board certification is sufficient.
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FAQ ID:93886
SHARE URLUnder CMS 2370-F, if a physician is board certified in a non-eligible specialty (for example dermatology) but practices within the community as for, example, a family practitioner and attests to meeting the 60 percent claims threshold, are we expected to audit his or her practice and, if so, how? May we be specific about our audit requirements in the state plan?
Since the only evidence of eligibility is the self-attestation and claims history, the state would need to take steps to verify the practice characteristics of the physician. This could be done by determining that the physician represents himself in the community as a family practitioner, as evidenced by medical directory listings, billings to other insurers, advertisements, etc.
While we have no objection to the addition of this information to the state plan amendment (SPA), we believe it is more important that the state make providers aware of the audit procedures and requirements as part of the enrollment process.
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FAQ ID:93891
SHARE URLUnder CMS 2370-F, there are several codes for which there are relative value units (RVUs), but a rate does not calculate for the non-facility setting. For example, 99217-99221 (observation codes) only have a facility fee. If the state is electing the option of paying the non-facility fee, should it use the facility fee or is there an alternative method for calculation?
When there are RVUs for just one site of service the state should use those RVUs. There is no alternate method for calculation.
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FAQ ID:93896
SHARE URLIn our state, the Medicaid agency instructs Rural Health Centers (RHCs) to bill the Medicaid agency for the administration of a Vaccines for Children Program (VFC) immunization by using the provider's individual provider number for each immunization administration and the RHC/Medicaid group number for payment to the RHC for other medical services. Under the CMS 2370-F rule, do RHC's not qualify for enhanced payments on E&M codes billed with the RHC Medicaid facility provider number, but the individual providers do qualify for enhanced payment on VFC administration? Given that my state also requires RHCs to bill for E&M hospital codes such as 99221 or 99223 by using the individual treating provider's number, shouldn't the individual providers be "qualifying" providers for the purpose of enhanced payments for these hospital codes?
Providers such as RHCs and Federally Qualified Health Centers (FQHCs) are reimbursed on the basis of an all-inclusive rate under their own Medicaid benefit categories. As specified in the final regulation, only services provided under the physician benefit and billed using a physician fee schedule are eligible for higher payment. In your examples, since the state reimburses the vaccine administration and the hospital codes on a fee-for-service basis and does not pay then all-inclusive rate, those services would be eligible for higher payment if the physician who provides them properly self attests to eligibility. However, services provided by the physician that are reimbursed through the all-inclusive rate would not be eligible.
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FAQ ID:93901
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