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
Will a state receive 100 percent federal matching funds for new codes added to the fee schedule in CYs 2013 and 2014 under CMS 2370-F?
A state may not add any of the eligible service codes solely for the purpose of obtaining enhanced federal matching funds. For example, a state may not eliminate a code currently in use and attempt to substitute it with another Evaluation and Management (E&M) code. However, we recognize that a handful of codes have been added to the E&M code set since 2009. States which added those codes to their fee schedules will receive higher match for those services.
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FAQ ID:91351
SHARE URLThe notice of proposed rulemaking (NPRM) provided that states were required to pay the lesser of the provider's charges or the applicable Medicare rate. The final rule under CMS 2370-F no longer specifies this. Can a state continue to pay at the lower of the two amounts?
Under Medicare and Medicaid principles, payment is to be made at the lower of provider charges or the rate, which in this case is the applicable Medicare rate. This language was inadvertently omitted from the final rule. The Center for Medicare & Medicaid Services (CMS) is processing a technical correction to the regulatory text at 42 CFR 447.405 to restore this language.
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FAQ ID:91356
SHARE URLDoes higher payment apply to CHIP under CMS 2370-F?
The primary care provider rate increase does apply to the Children's Health Insurance Program (CHIP) Medicaid expansions but not separate (stand-alone) CHIPs. Qualified physicians who render the primary care services and vaccine administration services specified in the regulation will receive the benefit of higher payment for services provided to these Medicaid beneficiaries.
The State will receive 100 percent federal matching funds for the difference between the rate in effect 7/1/09 and the rate in calendar years (CYs) 2013 and 2014. The remainder of the payment will be funded at the CHIP matching rate, through the CHIP allotment. Services provided under separate (standalone) CHIPs are not eligible for higher payment.
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FAQ ID:91361
SHARE URLThe rule under CMS 2370-F indicates that all limitations, conditions and policies that applied to the code prior to January 1, 2013 can be applied to the code after that date. If a state sets a reduced rate for a Level III emergency service (99283) if it is a triage service (based on criteria described in the state plan) can it continue to do so or must it pay 100 percent of the Medicare rate? If it can continue to reduce the rate, must it develop a "Medicare triage rate", or can it continue to use the Medicaid triage fee?
This rule does not affect the state's ability to define and operate its coding system, and a state could distinguish claims submitted from those otherwise identified with code 99283. For those claims, the state should develop a rate that it believes Medicare would pay if Medicare made a similar distinction for emergency services limited to triage services, and would then pay that rate. For claims that were not limited to triage services, the state would pay based on the established Medicare rate for code 99283.
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FAQ ID:91366
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:91376
SHARE URLCan states require hospital employees to take and pass knowledge tests in order to make PE determinations?
Yes, in order to ensure that hospitals comply with the agreement to make presumptive eligibility determinations consistent with state policies and procedures, states have the flexibility to require hospitals to have the staff that will do PE determinations take and pass knowledge tests in order to make PE determinations. Since the PE enrollment process does not require detailed knowledge of Medicaid eligibility policy, the test should be appropriately geared to the information needed to make an appropriate decision and comply with state procedures.
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- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)
FAQ ID:91691
SHARE URLIs there a requirement that states use the two performance metrics CMS described in the final rule?
The use of the two performance metrics CMS described in the final rule at section 435.1110 (the proportion of individuals determined PE who submit a full application and the proportion of those who submit an application who are deemed to be Medicaid eligible) is optional for states. States may choose to use other or additional metrics in their hospital PE programs. All states should collect data on hospital performance to fulfill their oversight responsibilities.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)
FAQ ID:91696
SHARE URLWhat types of performance standards are states considering beyond the two options CMS presents in the final rule?
States are considering a number of different types of performance standards, including the proportion of hospital PE determinations made in an outpatient setting (given that a strong incentive exists for determinations in inpatient settings but it is desirable to also implement PE for outpatients to ensure reaching as broad a population as possible) and the number of hospital PE applications completed in one month. Other states are collecting baseline data in order to measure hospital performance and plan to establish specific standards at a later point.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)
FAQ ID:91701
SHARE URLWhat federal matching rate applies for individuals found presumptively eligible by hospitals? Is the newly eligible federal medical assistance percentage (FMAP) available for populations found presumptively eligible for the new adult group?
While individuals may be determined "presumptively eligible" for coverage under the new adult group by a qualified hospital or qualified entity, the newly eligible FMAP is only available once the full eligibility determination has been completed. In these circumstances, the newly eligible FMAP is only authorized with respect to individuals determined eligible for the new adult group by the state agency or other public entity authorized to make final Medicaid eligibility determinations. The regular FMAP applies until such time as the state (or other authorized entity) determines an individual to be eligible for the new adult group and the state confirms that they also meet the definition of a "newly eligible individual."
As noted in our August 2013 FAQs, in appropriate circumstances, a state may retroactively adjust claiming for services provided during a presumptive eligibility period. Specifically, newly eligible status is available based on the effective date of eligibility for the new adult group, which may be as early as the third month prior to the month that the individual applied for Medicaid in accordance with 42 CFR section 435.914 (re-designated at section 435.915 under the March 2012 final eligibility rule), provided that the individual would have been eligible for Medicaid had he or she applied as of the earlier date. To the extent to which the presumptive eligibility period is encompassed within such retroactive eligibility period and the state determines that the individual meets the criteria for newly eligible status, the state may retroactively adjust claiming for services provided during a presumptive eligibility period. The state is not required to make such a retroactive adjustment if the state determines that an adjustment would be administratively burdensome.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)
FAQ ID:91706
SHARE URLCan a state make a qualified hospital liable when a PE determination results in a denial of Medicaid eligibility?
There is no recoupment for Medicaid services provided during a PE period resulting from erroneous determinations made by qualified entities. Payment for services covered under the state plan (as well as federal financial participation) is guaranteed during a PE period; without such a guarantee, providers could not rely on the PE determination. As noted, states have various ways to ensure that hospitals are making appropriate PE determinations and must fulfill their oversight responsibilities.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)
FAQ ID:91711
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