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
Now that Upper Payment Limit (UPL) demonstrations are submitted to a central e-mailbox, will the CMS Regional Office still have a role in reviewing UPL demonstrations or will the review be performed by the Central Office?
The Regional Office will continue to review state UPL demonstrations and states will continue to work with the CMS Regional Offices as a first point of contact concerning their UPL demonstrations.
FAQ ID:92256
SHARE URLHow should Upper Payment Limit (UPL) supplemental payments be entered in the template?
The state should report the expected amount of supplemental payments to be made during the period covered by the UPL demonstration. Supplemental payments should be entered into variables 303.1, 303.2, and 303.3 for the Inpatient Hospital and Outpatient Hospital templates and 313.1, 313.2, and 313.3 for the Nursing Facility templates. The state should provide detail in the notes tab on the types of supplemental payments and the related dollar amount of each payment.
FAQ ID:92291
SHARE URLCan the Outpatient Hospital (OPH) Services Upper Payment Limit (UPL) demonstration consider Clinical Diagnostic Laboratory (CDL) services?
Section 1903(i)(7) of the Social Security Act specifies a separate UPL for CDL services which limits payment to no more than the Medicare rate on a per test basis. To meet the statutory provision, the UPL for CDL services must be separately demonstrated from the OPH services UPL. States do not have the ability to "borrow room" from the CDL UPL and apply it to the OPH UPL.
FAQ ID:92401
SHARE URLOur understanding of the CMS 2370-F rule is that advanced practice clinicians are eligible for the increased payment as long as they are working under the personal supervision of an eligible physician; eligible meaning the supervising physician is also eligible for the increased payment.
The Center for Medicare & Medicaid Services (CMS) has permitted states flexibility in establishing processes to identify services provided by advanced practiced clinicians (APCs), including advanced practice nurses, being personally supervised by eligible physicians who accept professional responsibility for the services they provide. The state may set up a separate system to document that an Ambulatory Payment Classification (APC) is working under the personal supervision of a particular eligible physician. For example, the eligible physician could identify the APCs to the Medicaid agency, which could flag the claims submitted by those APCs under their own provider numbers through the Medicaid Management Information System (MMIS). There is no requirement that the rendering providers indicate on each claim the name of the supervising eligible physicians, however it is important that there be documentation that the eligible physicians have acknowledged their relationship with the advanced practice clinicians. Providing this type of information on a per claim basis is an effective way to document the state's claim for 100 percent federal funding for the increased portion of the payment.
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FAQ ID:92106
SHARE URLWho can I contact for technical assistance questions, as well as information about state Medicaid prevention efforts and section 4004(i) of the Affordable Care Act?
Technical assistance questions, as well as information about state Medicaid prevention efforts, can be directed to: MedicaidCHIPPrevention@cms.hhs.gov and/or Deirdra Stockmann, 410-786-2433.
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FAQ ID:91501
SHARE URLWill retroactive provider payments by health plans - necessitated by the State's retroactive payment of the higher rates to health plans - be subject to timely claims filing requirements in 42 CFR 447.46? If so, may states impose liquidated damages or other penalties on health plans for violating those requirements?
Any retroactive payments made to providers in order to ensure that eligible providers receive the applicable Medicare rate for eligible services will not be considered claims subject to the requirements in 42 CFR 447.46.
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FAQ ID:91411
SHARE URLCan managed care plans under contract with a state use their own definitions of primary care providers and services for purposes of complying with CMS 2370-F rule?
While we recognize that health plans may have unique definitions of primary care providers and services, the availability of the increased Federal Medical Assistance Percentage (FMAP) is limited to the scope of eligible primary care providers and primary care services as defined in statute and implemented by this rule.
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FAQ ID:91416
SHARE URLWhen will the Centers for Medicare & Medicaid Services (CMS) provide standardized contract language reflecting the requirements of this provision as mentioned during the All-State Call on November 8th?
CMS will be working collaboratively with the National Association of Medicaid Directors (NAMD) to develop the contract elements necessary to reflect the requirements of this rule. In recognition of the State Medicaid Agency's role in the contracting practice, CMS will describe the suggested content areas rather than issue standardized contractual language. These elements will be described in further detail in a future (Question and Answer) Q&A document.
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FAQ ID:91421
SHARE URLHow will states with Medicaid managed care programs comply with the requirement to report provider participation levels specified in 42 CFR 447.400(d)(1)?
At this time, the Center for Medicare & Medicaid Services (CMS) is not defining the form of information required under 42 CFR 447.400(d)(1), but we do suggest that states with Medicaid managed care programs conduct a baseline assessment of primary care access before the provision goes into effect. This baseline assessment will ensure that Congress, CMS, and researchers have comparative data to evaluate this provision.
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FAQ ID:91426
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
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