Frequently Asked Questions

The cost of the tax should be reported in Variable 401 - MCD Provider Tax Cost. A state may separately report the Medicaid portion of the cost of a provider assessment/tax only when it is using a cost based methodology to calculate the UPL. A state may not include this cost when calculating a DRG or Payment based UPL demonstration.

FAQ ID:92366

No, the template does not include variables to report clinical diagnostic laboratory services.

FAQ ID:92371

The Notes tab should include any and all information to fully support the state's UPL demonstration. CMS expects states to provide clarifying information in the Notes tab. For example, this information would provide details for the adjustments to Medicare as input in variables 212.1 and 212.2, various supplemental payments in variables 313.1, 313.2, and 313.3, and adjustments to Medicaid in variables 314.1 and 314.2. In addition to reporting through the notes tab, the state also has the option of using the guidance document or narrative to fully support its UPL demonstration.

FAQ ID:92376

No, facilities that are licensed, covered, and paid under the Medicaid state plan as inpatient hospital or nursing facilities should be included in the UPL calculated for those services. There is no regulatory requirement to conduct separate calculations for designated facility "types" within each of the applicable service categories. States do not need to provide separate UPL demonstrations for IMDs covered under the inpatient hospital or nursing facility services benefit.

FAQ ID:92381

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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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:92106

Implementing regulations at 42 CFR 438.804 require states to submit to CMS a methodology for calculating the July 1, 2009, baseline rate for eligible primary care services and a methodology for calculating the rate differential eligible for 100 percent of Federal Financial Participation (FFP) by March 31, 2013. Further, 42 CFR 438.6 (c)(5)(vi) establishes Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PHIP) or Prepaid Ambulatory Health Plan (PAHP) contract requirements to comply with this provision. It is CMS's expectation that as soon as practicable after the State submits the required methodologies in 42 CFR 438.804 and receives CMS approval, the State will:

1. Submit revised actuarial certification documents reflecting the Medicare rate for eligible primary care services in their MCO, PIHP or PAHP capitation rates; and
2. Submit amendment(s) to this contract to ensure compliance with 42 CFR 438.6 (c)(5)(vi).

After CMS approval of the revised contract and rates, the MCO, PIHP or PAHP must direct the full amount of the enhanced payment to the eligible provider to reflect the enhanced payment effective January 1, 2013. Federal financial participation (FFP) is available at a rate of 100 percent for the portion of capitation rates attributable to these enhanced payments; however, receipt of the enhanced FFP is contingent upon the state's successful completion of this process.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91266

The newly eligible FMAP (described in section 1905(y)(1) of the Act) is 100 percent in calendar years 2014-2016, 95 percent in calendar year 2017, 94 percent in calendar year 2018, 93 percent in calendar year 2019, and 90 percent in calendar years 2020 and beyond.

For states who opt to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, for calendar years 2014-2016, the one percentage point increase for newly eligible individuals wouldn't apply, as the FMAP for that group is 100 percent.

Starting in 2017 and beyond, when the newly eligible FMAP goes to 95 percent and below, the one percentage point increase for the services mentioned in section 4106 of the Affordable Care Act would apply to the newly eligibles. Example: For 2017, newly eligibles would receive 95 percent FMAP. If the state opts to provide the services mentioned in section 4106 of the Affordable Care Act without cost sharing, per the guidelines in State Medicaid Director Letter (SMDL) 13-002, the state would receive 96 percent FMAP on such services for the newly eligibles.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91621

Yes, that is correct. The one percentage point FMAP increase under section 4106 applies only to the FMAP set forth under section 1905(b) and section 1905(y) of the Act; it does not apply to FMAP rates under section 1903(a) of the Act. However, any family planning related service that also is recognized by section 4106 and matched at the state's regular FMAP is eligible to receive the one percentage point FMAP increase.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91636

If the state is meeting the requirements outlined in State Medical Director (SMD) letter #13-002, the state may receive the one percentage point FMAP increase on the Medicaid liability after coordination of benefits occurs.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91646

Clinical preventive services that receive an I or C recommendation are eligible for Medicaid coverage. States determine medical necessity criteria, and determine whether they will cover I or C recommended services. However, United States Preventive Task Force (USPSTF) grade I and C recommended services are not eligible for the one percentage point federal medical assistance percentage (FMAP) increase.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91661