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 CMS MMIS certification support non-traditional claims processing models, such as using an Administrative Services Organization or "claims processing as a service" approach?
Yes. The certification checklist defines a set of business and technical requirements that a particular Medicaid function must meet. The checklists and criteria are agnostic as to whether the requirements are met by a system built within the Medicaid Agency, a Software-as-a-Service model, a cloud-hosted model, or an ASO model.
FAQ ID:94461
SHARE URLIs MITA considered during milestone reviews?
Yes, our milestone review process is fully aligned with MITA. During each milestone review, CMS will verify that the state has considered MITA maturity during system definition, and whether the state is actively moving toward higher MITA maturity as defined in the state's latest MITA State Self-Assessment. Please see 42 CFR 433.112 (b)(11).
FAQ ID:94476
SHARE URLI am a vendor not currently in the Medicaid space, but interested in learning more about opportunities for MMIS and/or E&E modular solutions. Whom can I contact for more information?
CMS is looking for new innovators in the Medicaid IT space. Please direct inquiries to: mmis_mes_certification@cms.hhs.gov.
FAQ ID:94416
SHARE URLI am an existing MMIS vendor under contract with a state. Who do I contact with questions about the new certification process?
Please work with your state representatives, so that they can contact CMS regional offices for quick assistance with your questions. In addition, please review other FAQs related to this topic.
FAQ ID:94431
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.
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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.
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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
SHARE URLAre there any limitations around the use of the data year (e.g., 2013) or the fee year (e.g., 2014) as the base for any adjustment to the capitation rates to account for the Health Insurance Providers Fee?
There are reasonable ways to account for the Health Insurance Providers Fee as an adjustment to the states' capitation rates under either approach. In either approach, the amount of the fee should be incorporated as an adjustment to the capitation rates and the resulting payments should be consistent with the actual or estimated amount of the fee.
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FAQ ID:91161
SHARE URLIf the 2014 capitation rates are being adjusted to reimburse health plans for the Health Insurance Providers Fee due in 2014, should the adjustment be applied to every population?
No. Since the fee due in 2014 is based on the health plan's 2013 book of business, the adjustment should only apply to the capitation rates for populations that the state covered under the managed care contract in 2013. For example, states that chose to expand Medicaid eligibility starting January 1, 2014, should not adjust the capitation rates for the new adult eligibility group to account for the fee due in 2014, because they were not covered by the managed care plans in 2013. In future years, the Health Insurance Providers Fee will continue to be based on the book of business for the immediately preceding year, so this concept will apply in calculating the fee if any new populations are added to a state's managed care program.
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FAQ ID:91181
SHARE URLShould the potential effect of the Health Insurance Providers Fee on other taxes, fees, and assessments and the non-deductibility of the fee be considered in the development of capitation rates?
The potential effect of the fee may be considered in the development of the capitation rates. If the state's actuary takes these potential effects into account in developing the non-benefit component of the capitation rate attributable to the Health Insurance Providers Fee, the assumptions underlying that analysis will be documented in the rate certification.
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FAQ ID:91196
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