Frequently Asked Questions

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

If the United States Preventive Services Task Force (USPSTF) grade A or B service is an integral part of the office visit that includes other services, and will not be billed separately, the state may permit providers to charge a copay for the office visit, as the office visit is not eligible for the one percentage point FMAP increase. If the USPSTF grade A or B service is billed separately, or is the only service furnished during the office visit, the state may not permit the provider to charge a copay. The state should work with providers to establish the appropriate billing codes and claims processing guidelines for these situations.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92121

The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91991

It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91996

Provided that the services are medically necessary, states are required to follow only the summary of recommendations for the services that have a rating of A or B from the United States Preventive Services Task Force (USPSTF). It is up to the state to have a financial monitoring procedure to ensure proper claiming for federal match.

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FAQ ID:92006

The state may claim the 1% FMAP increase on both the professional component (interpretation of the x-ray) and the technical component (the actual taking of the x-ray).

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FAQ ID:92011

States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all United States Preventive Services Task Force (USPSTF) grade A and B preventive services and approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP), and their administration, without cost-sharing. An approved state plan amendment is required for the lines to be enterable on the CMS-64 form. As with all other services claimed on the CMS-64, the amounts reported on and its attachments must be actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. The CMS-64 report form has been modified to allow for reporting of a state's managed care expenditures separate from the state's reporting of fee-for-service (FFS) expenditures. The total expenditures associated with services referenced in section 4106 would be reported on the requisite lines for managed care (line 18A4, 18B1d or 18B2d) and for FFS (line 34A).

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92021

States that elect to cover all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and vaccine administration, without cost-sharing and who receive a SPA approval for such services shall receive the one percentage point FMAP increase per section 4106. Some of these services may also qualify as 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 FMAP rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act were followed.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92031