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.

The American Medical Association created modifier 33 in response to the Affordable Care Act requirements pertaining to preventive services. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a United States Preventive Services Task Force (USPSTF) A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.

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It is up to the state to set up its payment methodologies and procedures. To the extent that the state processes a claim for a United States Preventive Services Task Force (USPSTF) grade A or B preventive service consistent with those procedures, it can claim the enhanced match for that claim. If the state elects a payment methodology using bundled services, generally it cannot claim the enhanced match. But there may be some instances in which it might be appropriate to allocate costs for bundled claims among the included components. To the extent that a state is interested in doing so, it must develop a cost allocation plan, and submit that for CMS approval.

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Provided that the services are medically necessary, states are required to follow only the summary of recommendations for the services that have a rating of A or B from the United States Preventive Services Task Force (USPSTF). It is up to the state to have a financial monitoring procedure to ensure proper claiming for federal match.

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The state may claim the 1% FMAP increase on both the professional component (interpretation of the x-ray) and the technical component (the actual taking of the x-ray).

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States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all United States Preventive Services Task Force (USPSTF) grade A and B preventive services and approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP), and their administration, without cost-sharing. An approved state plan amendment is required for the lines to be enterable on the CMS-64 form. As with all other services claimed on the CMS-64, the amounts reported on and its attachments must be actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and is available immediately at the time the claim is filed. The CMS-64 report form has been modified to allow for reporting of a state's managed care expenditures separate from the state's reporting of fee-for-service (FFS) expenditures. The total expenditures associated with services referenced in section 4106 would be reported on the requisite lines for managed care (line 18A4, 18B1d or 18B2d) and for FFS (line 34A).

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States that elect to cover all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines and vaccine administration, without cost-sharing and who receive a SPA approval for such services shall receive the one percentage point FMAP increase per section 4106. Some of these services may also qualify as primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services, the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular FMAP rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act were followed.

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As long as the state covers all United States Preventive Services Task Force (USPSTF) grade A and B services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing, such services will be eligible for the one percentage point federal medical assistance percentage (FMAP) increase. State Medicaid agencies should work with, and communicate to, providers concerning state-specific systems and the appropriate codes to use.

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We recognize that an E&M service may include a United States Preventive Services Task Force (USPSTF) grade A or B service (for example, blood pressure screening). To receive the one percentage point federal medical assistance percentage (FMAP) increase, states are required to cover in their standard Medicaid benefit package all USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing. It is up to the state to determine how the billing should occur. In the examples mentioned above, if you consider these USPSTF grade A or B recommended services to be an integral part of the office visit, and they will not be billed separately, the state may continue that billing practice. The state may claim the one percentage point FMAP increase on the office visit only if the primary purpose of the office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. The state should work with providers and payers to ensure that Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services are followed. We wish to confirm that a state must be able to document expenditures claimed on the CMS-64 and we believe the best way to accomplish this is through the billing process.

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All USPSTF grade A and B services, and ACIP recommended vaccines and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase. The Department of Health and Human Services, in implementing the Affordable Care Act under the standard set out in revised section 2713(a)(5) of the Public Health Service Act, utilizes the 2002 recommendations on breast cancer screening of the USPSTF. Therefore, we are adopting a flexible approach for states to receive a one percentage point FMAP increase for breast cancer screening. States can choose to use either the 2002 USPSTF grade B recommendation or the most current USPSTF recommendation (which is the grade B recommendation updated in 2009). The 2002 USPSTF recommendation is that women age 40 years and older should receive a screening mammography everyone to two years. The 2009 USPSTF recommends biennial screening mammography for women aged 50 to 74 years of age.

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