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
Who can tell me if I am eligible for Medicaid?
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Since Medicaid is administered by the Medicaid agency in your state, eligibility may vary from one state to another. Contact your state Medicaid Agency with questions, or see if you qualify by applying. CMS is the federal agency that works with state Medicaid agencies to make sure they comply with federal laws and regulations.
FAQ ID:94506
SHARE URLI want to apply for Medicaid or get coverage for my child. Who do I contact?
Your state will determine if you qualify for Medicaid. Contact your state for renewal or application information.
FAQ ID:94516
SHARE URLI want to talk to someone at the federal level. Who do I contact?
State Medicaid and CHIP agencies have the primary responsibility for operation of the Medicaid and CHIP programs and they are your first and primary resource for assistance with your Medicaid and CHIP related questions, particularly as it relates to your eligibility status or benefits. If you have already contacted your State Medicaid Agency, you may contact the Centers for Medicare and Medicaid Services as follows:
Toll-Free: 877-267-2323
Local: 410-786-3000
TTY Toll-Free: 866-226-1819
TTY Local: 410-786-0727
Medicaid.gov Mailbox: Medicaid.gov@cms.hhs.gov
FAQ ID:94561
SHARE URLHow should states account for the cost of the Health Insurance Providers Fee in their actuarially sound capitation rates?
States and their actuaries have flexibility in incorporating the Health Insurance Providers Fee into the state's managed care capitation rates. This fee is not unlike other taxes and fees that actuaries regularly reflect in developing capitation rates as part of the nonbenefit portion of the rate. CMS believes that the Health Insurance Providers Fee is therefore a reasonable business cost to health plans that is appropriate for consideration as part of the non-benefit component of the rate, just as are other taxes and fees.
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FAQ ID:91126
SHARE URLWhat methodologies are acceptable to account for the Health Insurance Providers Fee in capitation rates? Can states make retroactive adjustments to the capitation rates once the actual assessments on the health plans are known?
States have the flexibility to account for the Health Insurance Providers Fee on a prospective or retroactive basis. In the event that a prospective calculation results in a capitation rate that is too high or too low, the capitation rate may be adjusted after the actual tax assessment is known. States may also account for the fee prospectively by withholding such amounts until the health plan's actual fee is known. The capitation payment, net the amount of the withhold, must remain actuarially sound and the state can only claim Federal Financial Participation (FFP) on the actual expenditures paid from the withhold to reimburse the health plans for the fee.
States may account for the Health Insurance Providers Fee as an aggregated retroactive adjustment to the rates for the contract year once a health plan's liability is known. CMS anticipates that states would move to a prospective calculation as states and health plans obtain more experience with the fee.
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FAQ ID:91141
SHARE URLCan the Health Insurance Providers Fee be paid to health plans as a separate payment after the plans' fee liability is known?
No. There is no Federal Financial Participation (FFP) available for Health Insurance Providers Fee payments made outside of actuarially sound capitation rates, per the requirements of section 1903(m)(2)(A(iii) of the Social Security Act and implementing regulations at 42 CFR 438.6(c)(2). Therefore, any payment for the fee-whether on a prospective or retrospective basis-must be incorporated in the health plan capitation rates and reflected in the payment term under the contract.
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FAQ ID:91151
SHARE URLAre there any limitations around the use of the data year (e.g., 2013) or the fee year (e.g., 2014) as the base for any adjustment to the capitation rates to account for the Health Insurance Providers Fee?
There are reasonable ways to account for the Health Insurance Providers Fee as an adjustment to the states' capitation rates under either approach. In either approach, the amount of the fee should be incorporated as an adjustment to the capitation rates and the resulting payments should be consistent with the actual or estimated amount of the fee.
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FAQ ID:91161
SHARE URLIf the 2014 capitation rates are being adjusted to reimburse health plans for the Health Insurance Providers Fee due in 2014, should the adjustment be applied to every population?
No. Since the fee due in 2014 is based on the health plan's 2013 book of business, the adjustment should only apply to the capitation rates for populations that the state covered under the managed care contract in 2013. For example, states that chose to expand Medicaid eligibility starting January 1, 2014, should not adjust the capitation rates for the new adult eligibility group to account for the fee due in 2014, because they were not covered by the managed care plans in 2013. In future years, the Health Insurance Providers Fee will continue to be based on the book of business for the immediately preceding year, so this concept will apply in calculating the fee if any new populations are added to a state's managed care program.
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FAQ ID:91181
SHARE URLShould the potential effect of the Health Insurance Providers Fee on other taxes, fees, and assessments and the non-deductibility of the fee be considered in the development of capitation rates?
The potential effect of the fee may be considered in the development of the capitation rates. If the state's actuary takes these potential effects into account in developing the non-benefit component of the capitation rate attributable to the Health Insurance Providers Fee, the assumptions underlying that analysis will be documented in the rate certification.
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FAQ ID:91196
SHARE URLHow should states address the exclusion of long-term care premiums from the plan's Health Insurance Providers Fee calculation?
Section 9010(h)(3) of the Affordable Care Act and the IRS Health Insurance Providers Fee regulations (78 FR 71476, 71483, November 29, 2013; available at www.irs.gov/businesses/corporations/affordable-care-act-provision-9010) exclude long-term care from the definition of health insurance for purposes of calculating a health plan's fee liability. Where long- term care services are paid a capitation rate separate from other services, these payments can be easily identified and should be excluded by the health plan when reporting premiums subject to the fee to the IRS. However, where long-term care services are not easily identified within the health plan's capitation rates, the health plans may need to consult with the state and their actuaries to determine the appropriate premium receipts to report to the IRS.
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FAQ ID:91391
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