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
Has CMS mandated Applied Behavior Analysis (ABA) services for children under 21 with Autism Spectrum Disorder (ASD)?
No. Applied Behavior Analysis (ABA) is one treatment modality for ASD. CMS is not endorsing or requiring any particular treatment modality for ASD. State Medicaid agencies are responsible for determining what services are medically necessary for eligible individuals. States are expected to adhere to long-standing EPSDT obligations for individuals from birth to age 21, including providing medically necessary services available for the treatment of ASD.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)
FAQ ID:93386
SHARE URLWhen will CMS begin to assess state compliance with coverage requirements for children with Autism Spectrum Disorder (ASD)?
There is no specific time frame for CMS review of state practices in this area. The CMCS Informational Bulletin released July 7, 2014 (see http://www.medicaid.gov/Federal-PolicyGuidance/Downloads/CIB-07-07-14.pdf (PDF, 143.2 KB)), related to Autism Spectrum Disorder discusses the obligations under the Medicaid statute and regulations that are already in effect. However, CMS recognizes that states may not have focused on the application of these requirements in this area. As a result, a state may need time to review its current program policies to determine if changes are needed to existing state regulations and/or policy to ensure compliance. States may also want to confer with the stakeholder community for public input on the benefit design of autism services for children. CMS believes states should complete this work expeditiously and should not delay or deny provision of medically necessary services. CMS is available to provide technical assistance to states to ensure the availability of services that children may need.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)
FAQ ID:93401
SHARE URLDo states need to submit a Medicaid state plan amendment (SPA) to offer benefits to individuals with Autism Spectrum Disorder (ASD)?
In order to have services reimbursed under the Federal Medicaid program, a service must meet the definition of a coverable service under section 1905(a) of the Social Security Act. Treatment for ASD is not specifically referenced as a section 1905(a) service. However, some treatment modalities, or components of such treatment modalities, are within the scope of the federal Medicaid program under the following service categories: section 1905(a)(6) Other Licensed Practitioner (OLP), section 1905(a)(13) Preventive Services, and section 1905(a)(11) Therapies :. States may provide services to address ASD under each of these benefit categories. States will need to determine what, if any, steps are needed to implement this policy clarification. In keeping with the role of the Medicaid state plan as a comprehensive written statement of the nature and scope of services available under the state's Medicaid program, a SPA is strongly encouraged to articulate the state's menu of services for ASD treatment.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)
FAQ ID:93406
SHARE URLHow should a state that has a section 1915(c) home and community-based services waiver that is limited to EPSDT-age individuals but includes services related to Autism Spectrum Disorder (ASD) that are now available through the state plan respond to this policy clarification?
The ASD-related services should be provided through the Medicaid state plan for the EPSDT-eligible individuals, rather than the 1915(c) waiver. CMS will work with states to ensure that such services are able to be made available under the state plan. Accordingly, CMS with also work with states to remove the service from the 1915(c) home and community-based services waiver at the next amendment or renewal, whichever comes first.
Supplemental Links:
- This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)
FAQ ID:93241
SHARE URLWe are procuring a COTS solution. This prevents us from providing some of the technical evidence requested in the certification checklists. Will this pose a problem?
CMS encourages the use of COTS solutions where possible, and the milestone review process supports certification of COTS products. The review criteria are intended to be tailorable to support different solutions, including COTS. In this case, the technical criteria in the checklists that do not apply to COTS may be marked ""Not Applicable"" with an explanation as to why they do not apply.
FAQ ID:93986
SHARE URLHow many certification reviews will each state go through with CMS?
It depends. We consider various factors. If a state is developing a complete MMIS solution with one release date, then there will be three reviews: Project Initiation Review, Operational Milestone Review, and MMIS Certification Final Review. If a state has multiple release dates with a modular or agile approach, the state would have one set of three certification reviews with CMS for each module the state would like CMS to certify. Each state will start its certification effort by having an initial consultation with CMS to determine how CMS can schedule milestone reviews that fit with the state's plan.
FAQ ID:94011
SHARE URLOur state is using an agile approach to develop our MMIS and/or E&E replacement. How will the milestone review milestone review process support this approach?
CMS has developed a milestone review process that is flexible enough to be placed over several development methodologies. CMS wants to ensure that the milestone reviews benefit and do not burden the state. CMS works with each state individually to ensure that the timing of the milestones fit within the state's internal development timeline.
FAQ ID:94001
SHARE URLCan a state review providers whose claims meet the 60 percent threshold and assume that those providers would be automatically eligible?
Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
Supplemental Links:
FAQ ID:94276
SHARE URLWith respect to the use of board certification to confirm a physician's self-attestation for CMS 2370-F eligibility must the physician's board status be current or is initial board certification sufficient?
The certification must be current. If it has lapsed but the physician still practices as an eligible specialist the self-attestation would need to be supported with a 60 percent claims history.
Supplemental Links:
FAQ ID:94296
SHARE URLCMS clarified in the final rule for CMS 2370-F that, for out of state providers, the beneficiary's home state (e.g., state A) may defer to the determination of the physician's home state (e.g., state B) with respect to eligibility for higher payment. However, if states A and B receive different Medicare locality adjustments, which locality rate must be paid?
As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.
Supplemental Links:
FAQ ID:94361
SHARE URL