Frequently Asked Questions

Medicaid and the Children’s Health Insurance Program (CHIP) can reimburse states for expenditures incurred by Local Education Agencies (LEAs)/school districts for the costs of administrative activities that support the provision of medical services covered under Medicaid or CHIP. Examples of allowable Medicaid and CHIP administrative activities can be found on page 75 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming. In general, some categories where administrative activities can fall include:

• Medicaid and CHIP outreach.
• Facilitating Medicaid and CHIP eligibility determinations.
• Transportation-related activities in support of Medicaid and CHIP services.
  • Note, when the State claims federal financial participation (FFP) for necessary transportation as an optional medical service, the State must not also claim the same transportation expenditures as an administrative activity, which would result in duplicative reimbursement.
• Translation and interpretation services related to covered services.
• Program planning, policy development, and interagency coordination related to Medicaid and CHIP.
• Medicaid- and CHIP-related training.
• Referral, coordination, and monitoring of Medicaid and CHIP services (distinct from case management activities covered as a medical service).

FAQ ID:162306

Yes, States are expected to apply the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming guidance to all MAC programs for all entities. Both previous guidance documents issued by CMS, including the 1997 School-based Services Technical Review Guide and the 2003 School-based Administrative Claiming Guide, are superseded by the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.

FAQ ID:162336

First, the activities must be allowable as State program administrative activities. Secondly, the State and/or claiming unit must implement a methodology to properly identify and allocate Medicaid’s portion of cost associated with the allowable State program administrative activity. Finally, the identification and allocation of this cost must be documented in the State’s Public Assistance Cost Allocation Plan (PACAP). According to 45 C.F.R. § 95.517, State Medicaid agencies (SMAs) that intend to claim for allowable administrative activities must have an approved PACAP. As the PACAP is primarily used by the Federal cognizant agency to allocate cost incurred by one direct federal awardee, yet funded by another federal awardee, there may be instances where costs applicable to allowable State program activities are incurred and funded by the SMA. In this instance, the State may identify and allocate the cost via a Medicaid Administrative Claiming (MAC) Plan and include a reference to the identification and allocation of the cost via the MAC Plan in its PACAP.

FAQ ID:162321

CMS encourages SMAs to reimburse school districts their allowable costs of conducting Medicaid and CHIP administrative activities. School districts should work with SMAs to develop a plan to document their costs so that the SMA can distribute Medicaid and CHIP FFP to school districts in proportion to each district’s relative expenditures for Medicaid and CHIP administrative activities.

FAQ ID:162326

Managed Long Term Services and Supports (MLTSS) plan managers should provide training on proper documentation practices to care managers and other delegated staff. States and MLTSS plans could consider including data field entry options to remind care managers to record all results of the assessment, even if findings are negative, that is, the member does not have a problem or need assistance or services. For example, states and plans could include a question in the member’s record that requires the care manager to document both whether an assessment was performed and whether a problem was identified, along with another required field to include the details of the problem if there was a problem identified.

FAQ ID:89046

CMS understands that many managed care contracts include a general provision that incorporates changes in federal law during the course of the contract term. Amendments to approved contracts, or contracts under CMS review, for the purpose of updating regulatory citations is not necessary. However, the citations will need to be updated for the next contract year. Outdated regulatory citations in contracts without such a general provision will need to be updated for the next contract year.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93426

No. If a state does not have a state law or policy that requires CMS approval of the contract and capitation rates prior to the effective date of the contract, the 90 day timeframe is not applicable. However, as a general matter, states should submit the contracts and rates 90 days prior to the start of the contract term. CMS intends to provide future guidance on the prior approval requirements as a condition of claiming FFP in section 438.806, which are distinct from the requirements at section 438.3(a).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93431

There is a technical error in section 438.210(a)(2) as the cross-reference should have incorporated subpart B of part 441 rather than subpart B of part 440. All Medicaid beneficiaries under age 21 are entitled to EPSDT services, whether they are enrolled in a managed care plan or they are in fee-for-service. Under section 1905(r) of the Social Security Act (the Act), EPSDT services must include ""[s]uch other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and physical and mental illness and conditions discovered by the screening services, whether or not such services are covered under the State plan."" CMS intends to issue a regulatory correction to address this error. We also want to remind readers that sections 1902(a)(43) and 1905(r)(5) of the Act are applicable to the provision of EPSDT, despite not being expressly incorporated in part 441. Detailed guidance on EPSDT can be found in ""EPSDT"" A Guide for States: Coverage in the Medicaid benefit for Children and Adolescents, June 2014, available at https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf (PDF, 613.1 KB).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93436

No. CMS addressed this provision at page 27569 of the Final Rule. Section 438.4(b)(5) does not require there to be different assumptions (such as trend or age, gender, or regional rating) for each rate cell and does not prevent the use of the same assumptions across more than one rate cell. The prohibition on cross-subsidization among rate cells under the contact is to ensure prudent fiscal management and that the capitation rate for each rate cell is independently actuarially sound.

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FAQ ID:93441

No. For the rating periods for contracts starting on or after July 1, 2017, managed care plans may not maintain more than one level of appeal. Section 438.402(b) requires that MCOs, PIHPs, and PAHPs ""may have only one level of appeal for enrollees."" Note that states may modify managed care contracts to require managed care plans to provide one level of internal appeal in advance of the rating period for contracts starting on or after July 1, 2017, as subpart F in the 2002 final rule permitted states flexibility as to the number of internal appeals. Please see page 27509 of the Final Rule for additional explanatory information.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93446