Frequently Asked Questions

The federal financial participation (FFP) limitation imposed by section 1903(i)(27) of the Act applies only with respect to those items of durable medical equipment (DME) covered by a state’s Medicaid program that are also covered by Medicare. Items covered as DME by only one of the programs are not included. This statutory limitation also does not apply to items for which Medicaid is not the primary payer. The statute refers to state expenditures for DME, therefore all funds expended by the state Medicaid agency on purchasing the relevant DME items and for which the state is requesting federal matching funds needs to be accounted for in the demonstration. CMS suggests taking the entire amount spent on a certain DME item (i.e., per Healthcare Common Procedure Coding System code) and divide it by the total volume to get an average price per DME item for the purpose of the calculation tool. If states have specific questions please contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.

FAQ ID:93576

Yes. To the extent that Medicare classifies such items as DME equipment and such items are covered by Medicare, they are included in the FFP limit in the statute. Oxygen supplies are included in the DME limit on FFP according the Medicare definition on DME.

FAQ ID:93581

States have the flexibility to conduct their own analysis and use their own calculation tool to show compliance to the statute. CMS has received approval through the paperwork reduction act to have the calculation tool collection of information be used for ease of administration for states in their durable medical equipment federal financial participation limit demonstration reporting and analysis. CMS asks states not using the calculation tool to contact the resource mailbox: MedicaidDME@cms.hhs.gov.

FAQ ID:93586

For purposes of the federal financial participation (FFP) limit, Medicare claims volume will not be considered in the demonstration of the limit. Only Medicaid claims volume is relevant for the calculation of the FFP limit.

FAQ ID:93591

The Centers for Medicare & Medicaid Services (CMS) will analyze state data provided to CMS and return the detailed information comparing the data sent from the state to the lowest and average Medicare rates for the relevant DME in the state on the aggregate. CMS will work with states during 2018 to assist with reporting necessary information under the new statute, and will run data reports for states before the end of the year if requested. A state that wishes this review should contact the Medicaid DME team by email at: MedicaidDME@cms.hhs.gov.

FAQ ID:93596

States are not required to change how they pay for items because of the statute. If a Medicaid program only purchases Medicare capped rental items, then that is the payment and utilization we will compare to Medicare’s rates in determining the aggregate expenditures. States are not obligated to alter their coverage of durable medical equipment due to the statute.

FAQ ID:93601

For the aggregate demonstration of Medicaid expenditures, we intend to use the Medicare rates released for services on or after January 1 of each year. We would suggest that states setting their rates according to Medicare rates in the state plan would follow a similar practice. States are, of course, welcome to use the quarterly updates of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) if that’s their intention, but we are not requiring those rate updates beyond the January 1 DMEPOS update.

FAQ ID:93606

The submission package consists of the completed templates and any supporting documentation needed to understand the UPL demonstration. This could include the completed Guidance document and supporting documentation (in Microsoft Excel with formulas included, not as a PDF) that is necessary to further explain a state's UPL demonstration, and a summary spreadsheet that aggregates the UPL gap for each of the ownership categories (state government owned, non-state government owned, and private).

FAQ ID:92236

IV&V contractor activities must still be performed such as checklist evaluation, artifact review and preparation of IV&V Progress Reports. The state should provide a plan and timeline for how these activities will be supported and performed until the proper IV&V contract can be either procured or aligned with updated CMS guidance on IV&V.

FAQ ID:94866

As contained in the MECT standard RFP/contract language required by CMS, CMS does not cover activities that the state may require of the IV&V contractor during ongoing O&M. However, as Medicaid is moving away from monolithic single applications, it is expected that states will continuously update and replace modules in their enterprise. Therefore, IV&V should always have a role to ensure successful integration and testing.

FAQ ID:94881