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
May Medicaid managed care plans conduct outreach to their enrollees regarding the Medicaid eligibility renewal process?
There is no provision in 42 CFR 438.104 specifically addressing a Medicaid managed care plan's outreach to enrollees for eligibility purposes; therefore, it depends on the Medicaid managed care plan's contract with the state Medicaid agency. The federal regulation at 42 CFR 438.104 defines marketing as ""any communication, from an [Medicaid managed care plan] to a Medicaid beneficiary who is not enrolled in that entity, that can reasonably be interpreted as intended to influence the beneficiary to enroll in that particular [Medicaid managed care plan's] Medicaid product, or either to not enroll in, or to disenroll from, another [Medicaid managed care plan's] Medicaid product."" So long as information and outreach about the eligibility renewal process is neither directed to beneficiaries who are not enrolled with that Medicaid managed care plan, nor intended to influence the beneficiary to enroll in that particular Medicaid managed care plan-or to not enroll in, or disenroll from another Medicaid managed care plan-the activity is not within the scope of 42 CFR 438.104. Materials and information that purely educate an enrollee of that Medicaid managed care plan on the importance of completing the State's Medicaid eligibility renewal process in a timely fashion would not meet the federal definition of marketing. However, Medicaid managed care plans should consult their contracts and the state Medicaid agency to ascertain if other provisions exist that may prohibit or limit such activity.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)
FAQ ID:94396
SHARE URLIf an individual who may already be enrolled in a Medicaid managed care plan, or is eligible to enroll in a Medicaid managed care plan, calls the plan's customer service unit with questions about that plan's Medicaid MCO and/or QHP products, can the Medicaid managed care plan answer consumer questions without violating the Medicaid marketing rules at 42 CFR 438.104?
Yes. Responding to direct questions from consumers is not generally a violation of 42 CFR 438.104. Proactive consumer inquiries to a health plan for information about coverage options, benefits, or provider networks is no different than a consumer obtaining information from the health plan's website. So long as the limits on marketing are satisfied and respected (e.g., the information is accurate and does not mislead, confuse or defraud beneficiaries or the state Medicaid agency), responding to direct questions from potential enrollees with accurate information is not prohibited.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)
FAQ ID:94391
SHARE URLWhat federal matching rate will apply for services for which a higher payment is made under CMS 2370-F if the services also qualify for a higher FMAP under the provisions of section 4106 of the Affordable Care Act?
In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a 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 Federal Medical Assistance Percentage (FMAP) rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act are applicable.
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FAQ ID:91076
SHARE URLWhen will states begin making higher payment for Evaluation and Management services reimbursed fee for service under CMS 2370-F?
Effective for dates of service on and after January 1, 2013 through December 31, 2014, states are required by law to reimburse qualified providers at the rate that would be paid for the service (if the service were covered) under Medicare. Most states and the District of Columbia will need to submit a Medicaid state plan amendment (SPA) to increase Medicaid rates up to this level. The Centers for Medicare & Medicaid Services (CMS) has issued a state plan amendment (SPA) preprint for the purpose of expediting review and approval of the primary care payment increase.
For dates of service starting January 1, 2013 qualified providers are entitled to receive the higher payment in accordance with the approved Medicaid state plan amendment. States may not have attestation procedures or higher fee schedule rates in place on January 1, 2013. In that event, providers will likely continue to be reimbursed the 2012 rates for a limited period of time. Once attestation procedures are in place and providers are identified as eligible for higher payment, the state will make one or more supplemental payments to ensure that providers receive payment for the difference between the amount paid and the Medicare rate. Qualified providers should receive the total due to them under the provision in a timely manner.
A state may draw federal financial participation for the higher payments only after the SPA methodology is approved.
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FAQ ID:91271
SHARE URLWhich Medicaid providers qualify for payment under CMS 2370-F? Can physicians qualify solely on the basis of meeting the 60 percent claims threshold, irrespective of specialty designation? Would Board certified "general surgeons" qualify for higher payment if they actually practice as general practitioners?
The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS) the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment. Under the regulation, "general internal medicine" encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA. In order to be eligible for higher payment:
- Physicians must first self-attest to a covered specialty or subspecialty designation.
- As part of that attestation they must specify that they either are Board certified in an eligible specialty or subspecialty and/or that 60 percent of their Medicaid claims for the prior year were for the Evaluation and Management (E&M) codes specified in the regulation. It is quite possible that physicians could qualify on the basis of both Board certification and claims history.
Only physicians who can legitimately self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those specialties recognized by the American Board of Physician Specialties (ABPS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS) qualify.
It is possible that a physician might maintain a particular qualifying Board certification but might actually practice in a different field. A physician who maintains one of the eligible certificates, but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. Similarly, a physician Board certified in a non-eligible specialty (for example, surgery or dermatology) who practices within the community as, for example, a family practitioner could self-attest to a specialty designation of family medicine, internal medicine or pediatric medicine and a supporting 60 percent claims history. In either case, should the validity of that physician's self-attestation be reviewed by the state as part of the annual statistical sample, the physician's payments would be at risk if the agency finds that the attestation was not accurate.
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FAQ ID:91276
SHARE URLThe Affordable Care Act specifies increased payments for three primary care specialties: Family Medicine, General Internal Medicine and Pediatrics. The Final Rule interprets this language to include some subspecialties with a relation to the original three, but does not list the subspecialties. Please identify the subspecialists eligible for higher payment.
Subspecialists that qualify for higher payment are those recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). For purposes of the rule, "General Internal Medicine" encompasses "Internal Medicine" and all recognized subspecialties. The websites of these organizations currently list the following subspecialty certifications within each specialty designation:
ABMS
Family Medicine - Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine.
Internal Medicine - Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine: Transplant Hepatology.
Pediatrics - Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral
Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine.
AOA
Family Physicians - No subspecialties
Internal Medicine - Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology.
Pediatrics - Adolescent and Young Adult Medicine, Neonatology, Pediatric Allergy/immunology, Pediatric Endocrinology, Pediatric Pulmonology.
ABPS
The ABPS does not certify subspecialists. Therefore, eligible certifications are: American Board of Family Medicine Obstetrics; Board of Certification in Family Practice; and Board of Certification in Internal Medicine. There is no Board certification specific to Pediatrics.
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FAQ ID:91281
SHARE URLIs self-attestation required or may a state rely solely on information about Board certification gathered upon provider enrollment or data on a physician's MMIS claims history to determine eligibility for CMS 2370-F?
The rule requires that physicians first self-attest to an eligible specialty or subspecialty and then attest to either Board certification or an appropriate claims history. States cannot pay a physician without evidence of self-attestation.
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FAQ ID:91286
SHARE URLDoes the 60 percent threshold in CMS 2370-F include both Evaluation and Management (E&M) codes and vaccine administration codes?
Yes. The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes.
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FAQ ID:91291
SHARE URLThe American Board of Physician Specialties does not certify subspecialists. Which Board certifications would qualify a physician for higher payment under CMS 2370-F?
Physicians who are Board-certified by the ABPS in Internal Medicine, Family Practice, or Family Medicine Obstetrics would qualify for higher payment.
Physicians with a certification in Family Medicine Obstetrics are all certified first in family medicine with additional certification in obstetrics. They practice as family practitioners and are therefore able to self-attest to a qualified specialty. This is not true of individuals certified in obstetrics by either the ABMS or AOA who do not qualify for higher payment.
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FAQ ID:91296
SHARE URLCan a physician self-attest to Board certification or a supporting claims history after January 1, 2013, when the CMS 2370-F primary care payment increase begins but expect higher payment back to the beginning of the year?
States must have the appropriate self-attestations in hand before they can pay physicians at the higher rate. States can impose reasonable requirements regarding "retroactive" self-attestations to facilitate program administration. For example, a state could limit retroactive payments to the beginning of the month or quarter in which the attestation is submitted. However, physicians must be made aware of the payment provision and of the requirements concerning self-attestation before January 1, 2013 through state provider bulletin or manual systems or other mechanisms.
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FAQ ID:91301
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