Frequently Asked Questions

States are required to cover certain benefits and others are optional. To learn what your state covers, contact your state Medicaid agency. To learn more about the Federal rules around mandatory and optional services, visit the benefits page.

In order to receive the one percentage point FMAP increase, the state is required to submit a SPA with updated coverage pages. When a SPA is submitted with updated coverage pages, we will perform a review of the corresponding payment page(s). A state does not need to submit a SPA with revised payment pages, and conduct public notice, unless it wishes either to begin coverage and payment for these services or to change the existing payment rates (in other words, if the state already pays for the preventive services in some contexts, a payment SPA may not be needed if the state does not want to change the existing payment rate or methodology).

Supplemental Links:

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

The preventive services information should be placed in item (13)(c), preventive services, of the pre-print. The State Medicaid Director (SMD) letter #13-002 indicates the information that should be added to the 3.1-A (and at the state's option, the 3.1-B) coverage limitations pages. CMS is available to provide technical assistance before you submit the state plan amendment (SPA), or we can discuss the needed information during the review of your SPA.

Supplemental Links:

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

A state would have to submit a SPA to amend the preventive services benefit in the state plan. Once that SPA is approved, the state generally is eligible for the enhanced FMAP for such services. The state should review its managed care authority document (SPA, waiver or 1115 demonstration project) to ensure that it reflects the coverage and cost-sharing provisions (as appropriate) of the preventive services benefit. The state will have to amend its Managed Care Organization (MCO) contracts to reflect the scope of coverage and the absence of cost-sharing for the preventive services benefit. To claim that enhanced FMAP for managed care payments, CMS must review the methodology that the state intends to use to estimate the value of the preventive services benefit in its capitation rates.

Supplemental Links:

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

Yes, the one percentage point increase in federal medical assistance percentage (FMAP) applies to all USPSTF grade A and B recommendations, including new, updated, and reaffirmed within the past five years.

Supplemental Links:

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

No, fluoride varnish is not eligible for the one percentage point FMAP increase. In the future, if the United States Preventive Services Task Force (USPSTF) adds fluoride varnish to the A or B recommended preventive services, states will be required to cover the fluoride varnish with no cost-sharing. Per State Medical Director (SMD) letter #13-002, states should provide an assurance in the state plan indicating they have a method to ensure that, as changes are made to the USPSTF and the Advisory Committee on Immunization Practices (ACIP) recommendations, they will update their coverage and billing codes to comply with those revisions. As long as this assurance is in the state plan, states are not required to submit a state plan amendment each time the USPSTF or ACIP makes changes to their recommendations.

Supplemental Links:

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

States may only claim the one percentage point FMAP increase on services that adhere to the USPSTF grade A and B recommendations on age, gender, periodicity and other criteria as indicated in the summary of recommendations. For instances where the USPSTF grade A and B recommendations have expanded age, gender or periodicity levels due to clinical considerations, practitioners should document in the patient's medical record the necessity for exceeding the grade A and B recommendations, and states may claim the one percentage point FMAP increase. When billing for these services, payers may want to use modifier 33 to identify services that meet the criteria for the USPSTF grade A and B recommendations. Pursuant to page 2 of State Medical Director (SMD) letter #13-002, states should have a financial monitoring procedure in place to ensure proper claiming for federal match.

Supplemental Links:

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

For states seeking the one percentage point federal medical assistance percentage (FMAP) increase, the SPA requirements are indicated on pages 3 and 4 of the State Medicaid Director (SMD) letter #13-002. CMS will not provide a state plan template on section 4106 of the Affordable Care Act. However, staff are available to provide technical assistance prior to your SPA submission.

Supplemental Links:

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

All USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase.

Supplemental Links:

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

The United States Preventive Services Task Force (USPSTF) recommendation for tobacco use counseling for pregnant women is grade A. Therefore, tobacco use counseling for pregnant women shall receive the one percentage point increase in FMAP. In addition, section 4106 of the Affordable Care Act states "items and services described in subsection (a)(4)(D)". Therefore, the one percentage point increase pertains to the comprehensive tobacco cessation services for pregnant women that are described in section 4107 of the Affordable Care Act.

Supplemental Links:

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