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
Can you explain more about how the survey data from the Survey of Income and Program Participation (SIPP) will be reweighted to reflect state demographics for purposes of MAGI Conversion?
To produce reliable state-level results, income conversions using SIPP data will be based on the entire national sample that has been re-weighted to account for state demographic characteristics. The purpose of the reweighting is to ensure that the analysis is done using a population whose characteristics are similar to each state's actual population. The variables used in reweighting include age, parent status, gender, race/ethnicity, total household income as a percent of FPL, types of unearned income (whether the household has any unearned income and whether it includes child support), and whether or not an individual has child care expenses. The re-weighting will be done separately for each state and will ensure that the distribution of these characteristics (and combinations of these characteristics) matches state totals from the Census Bureau's Current Population Survey. In some states, a few of these categories will need to be combined due to small sample size. CMS will be releasing a brief on SIPP and the re-weighting adjustments.
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FAQ ID:93951
SHARE URLHow will populations that are currently eligible based on net income, but will not qualify based on MAGI in 2014, be treated? Will these individuals have an opportunity to enroll in another insurance affordability program after March 31, 2014 or their next redetermination, whichever is later?
As stated under section 1902(e)(14)(D)(v), if the application of the new MAGI-based methods would be the cause of an existing Medicaid beneficiary's (i.e., one determined eligible based on current methods and enrolled in the program prior to January 1, 2014) becoming ineligible for continued coverage based on income, the individual retains Medicaid eligibility until March 31, 2014 or the next scheduled renewal, whichever is later. If, at the appropriate time, an individual is determined to no longer qualify for the current eligibility group, under longstanding Medicaid rules the individual's eligibility must be assessed under other possible eligibility groups before Medicaid eligibility may be terminated (see section 435.930(b) and section 435.916(f)). In accordance with 435.1200, if the individual is no longer Medicaid eligible, the state agency must evaluate the individual for potential eligibility for enrollment in a qualified health plan (QHP) through the Affordable Insurance Exchange, or Marketplace, and for CHIP.
Since the eligibility rules for Medicaid, CHIP and enrollment in a QHP through the Exchange are aligned, we do not expect that the evaluation for potential eligibility for these other programs to pose a burden on state agencies. Once determined to be potentially eligible for another program, the regulations call for ensuring that the information concerning the potentially eligible individual is transferred electronically to the other program.
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FAQ ID:94091
SHARE URLCan a state review providers whose claims meet the 60 percent threshold and assume that those providers would be automatically eligible?
Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
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FAQ ID:94276
SHARE URLCMS clarified in the final rule for CMS 2370-F that, for out of state providers, the beneficiary's home state (e.g., state A) may defer to the determination of the physician's home state (e.g., state B) with respect to eligibility for higher payment. However, if states A and B receive different Medicare locality adjustments, which locality rate must be paid?
As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.
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FAQ ID:94361
SHARE URLWhen does the Centers for Medicare & Medicaid Services (CMS) plan to issue a correction to the mistake they noted during the call with Medicaid agencies regarding payment under CMS 2370-F at the lesser of a provider's billed charge or the Medicare rate?
The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.
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FAQ ID:94376
SHARE URLIf a physician presents a certificate for CMS 2370-F eligibility from one of the defined boards, can the certificate be used as the legal document verifying the physician's certification or does the State have to verify with the board that the physician is certified and that the presented certificate is still active and valid?
States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.
FAQ ID:92686
SHARE URLThe final rule for CMS 2370-F indicated that 100 percent Federal Financial Participation (FFP) is not available for stand-alone Children's Health Insurance Program (CHIP) plans. What criteria should be used to determine if a plan is a stand-alone CHIP plan? What agency will determine if a plan is a stand-alone CHIP plan?
The Center for Medicare & Medicaid Services (CMS) approves CHIP programs as stand-alone or Medicaid expansions. Information on whether or not a particular state operates a stand-alone or expansion program is available at http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Downloads/Map-CHIP-Program-Designs-by-State-.pdf (PDF, 120.65 KB).
FAQ ID:92696
SHARE URLFederally qualified health centers (FQHCs)/ rural health clinics (RHCs) which receive an encounter rate are excluded under the rule for CMS-2370 F. Are FQHCs/RHCs who are paid provider fee-for-service included in the increase?
FQHCs and RHCs are required by law to be paid at least prospective payment system (PPS) for core primary care services. Physician services are core FQHC and RHC services and, therefore, should not be reimbursed on a fee-for-service basis.
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FAQ ID:92701
SHARE URLIn our state, advanced practice nurses must have a collaborative practice agreement with a physician within 50 miles of their office. Under the collaborative practice agreement, a physician must review a certain percentage of the nurse's patient charts every 2 weeks. Such nurses bill independently using their own Medicaid number. Is the collaborative practice agreement enough documentation for an advance practice nurse, with at least 60 percent of services billed by the nurse for calendar year (CY) 2012 for
Increased payment is available for services provided by eligible physicians or for services provided under their personal supervision. This means that the physician accepts professional responsibility (and legal liability) for the services provided. It does not appear that the collaborative arrangement requires that the physician accept professional responsibility for each of the services provided by the nurses. Therefore, increased payment would not be available.
However, if the physician is required to accept professional responsibility for the services provided by the advanced practice nurses and the physician is eligible based on self-attestation to a specified primary care specialty designation supported by either appropriate Board certification or a 60 percent claims history, then increased payment would be available.
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FAQ ID:92706
SHARE URLIf the supervising physician does not self-attest to the physician specialty or subspecialty qualification under CMS 2370-F, can the physician supervise a mid-level provider? If the supervising physician self-attests to the 60 percent threshold, but not one of the defined specialty or subspecialty qualifications, can the physician supervise a mid-level?
The eligibility of services provided by mid-level/non-physician practitioners is dependent on 1) the eligibility of the physician and 2) whether or not the physician accepts professional responsibility for the services provided by the mid-level. As previously noted, physicians are eligible only if they first self-attest to a specified specialty designation and also to either being appropriately Board certified or having a 60 percent claims history.
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ÂFAQ ID:92711
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