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
Under CMS 2370-F, please explain when salaried primary care providers are eligible for the enhanced payment under section 1202 of the Affordable Care Act and whether the employing organization, i.e. a clinic, physician group or hospital, may retain any additional payment received pursuant to this provision.
Generally, the purpose of the 1202 payment increase is to directly benefit physicians performing primary care services. In the instance of salaried physicians, including those working for clinics or other employing organizations that bill on the Medicaid physician fee schedule, this could come in the form of an increased salary. Alternatively, where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.
FAQ ID:91081
SHARE URLUnder CMS 2370-F, are there circumstances in which the enhanced payment under section 1202 of the Affordable Care Act (ACA) will not be paid?
To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.
FAQ ID:91086
SHARE URLUnder CMS 2370-F, if a state uses vaccine product codes to pay for vaccine administration, must it submit a new ACA 1202 state plan amendment (SPA) when those product codes change?
States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.
FAQ ID:91091
SHARE URLUnder CMS 2370-F, must a state submit a new state plan amendment (SPA) if it chooses to provide coverage for a new Current Procedural Terminology (CPT) billing code within the range of E&M codes specified in the law and regulation?
Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.
FAQ ID:91096
SHARE URLWill CMS approve enrollment caps or periods of ineligibility in section 1115 demonstrations?
The Affordable Care Act provides significant federal support to ensure the availability of coverage to low-income adults. Enrollment caps limit enrollment in coverage on a first come, first serve basis. Periods of ineligibility delay or deny coverage for otherwise eligible individuals. These policies do not further the objectives of the Medicaid program, which is the statutory requirement for allowing section 1115 demonstrations. As such, we do not anticipate that we would authorize enrollment caps or similar policies through section 1115 demonstrations for the new adult group or similar populations.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93751
SHARE URLCan states that extend eligibility for adults and propose, through a section 1115 demonstration, changes to the delivery of health care services still be eligible for the increased federal match?
Demonstrations focused on changes to how health care services are delivered, such as the use of managed care, will not generally affect the state's matching rate. Please refer to our February 2013 FAQs (PDF, 135.35 KB), which provide further clarification on the two increased federal match rates: the newly eligible rate and the expansion state rate as well as the final FMAP rule published on April 2, 2013. Additionally, CMS issued two State Medicaid Director letters, on July 10, 2012, that provide guidance on how states can adopt integrated care models without the need for a section 1115 demonstration.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)
FAQ ID:93756
SHARE URLUnder CMS 2370-F, may practice managers or billing staff of large group practices and health systems attest on behalf of their physicians on the basis of information on board certification in the records of the practice or health system?
If these practices and health systems maintain the types of documentation described in the previous answer, FAQ45736, with respect to managed care organizations, attestation by the group or system would be acceptable. As previously noted, a physician actually must be practicing as an internist, pediatrician or family physician in order to be eligible for higher payment. Board certification does not always equate to practice characteristics. Therefore, attestation on the basis of information on board certification alone would not suffice.
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FAQ ID:93866
SHARE URLUnder CMS 2370-F, if a physician renders services in both the managed care and fee for service environments, must he or she self-attest to eligibility twice?
No. The attestation and eligibility are physician-specific. If a physician provides services both in a fee-for-service and managed care environment, they need only complete the process of attestation once in order to receive higher payment for all eligible services they provide. CMS expects all information on self-attestation to be fully available to the state, regardless of which party collected this information.
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FAQ ID:93871
SHARE URLUnder CMS 2370, may physicians who practice in two (or more) states meet the 60 percent threshold based on all services provided in all states, or must they qualify on the basis of the services they provide in each state?
States have the flexibility to count eligible services provided by a physician in neighboring states in meeting the 60 percent threshold, but are not required to do so.
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FAQ ID:93876
SHARE URLThere are at least two current procedural terminology (CPT) codes (99429 and 99499) for which there are no relative value units (RVU) and the state manually prices the services for purposes of Medicaid payment. Will CMS develop a Medicare-like rate for these codes under the CMS 2370-F rule?
These services would not be subject to the minimum payment standard set in the rule because there are no RVUs and there is no conversion factor associated with them. Therefore, a Medicare-like rate cannot be developed. The state may continue to reimburse them at the current Medicaid rate but enhanced federal financial participation (FFP) will not be available for those services.
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FAQ ID:93881
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