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
Can managed care plans under contract with a state use their own definitions of primary care providers and services for purposes of complying with CMS 2370-F rule?
While we recognize that health plans may have unique definitions of primary care providers and services, the availability of the increased Federal Medical Assistance Percentage (FMAP) is limited to the scope of eligible primary care providers and primary care services as defined in statute and implemented by this rule.
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FAQ ID:91416
SHARE URLWhen will the Centers for Medicare & Medicaid Services (CMS) provide standardized contract language reflecting the requirements of this provision as mentioned during the All-State Call on November 8th?
CMS will be working collaboratively with the National Association of Medicaid Directors (NAMD) to develop the contract elements necessary to reflect the requirements of this rule. In recognition of the State Medicaid Agency's role in the contracting practice, CMS will describe the suggested content areas rather than issue standardized contractual language. These elements will be described in further detail in a future (Question and Answer) Q&A document.
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FAQ ID:91421
SHARE URLHow will states with Medicaid managed care programs comply with the requirement to report provider participation levels specified in 42 CFR 447.400(d)(1)?
At this time, the Center for Medicare & Medicaid Services (CMS) is not defining the form of information required under 42 CFR 447.400(d)(1), but we do suggest that states with Medicaid managed care programs conduct a baseline assessment of primary care access before the provision goes into effect. This baseline assessment will ensure that Congress, CMS, and researchers have comparative data to evaluate this provision.
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FAQ ID:91426
SHARE URLWhat is the difference between "Medicaid Amount Reimbursed" vs. "Non-Medicaid Amount Reimbursed" in the State Drug Utilization Data (SDUD)?
A Non-Medicaid Reimbursed amount is any amount paid on a claim by parties other than Medicaid (e.g., other federal coverage, co-pay, private insurance). If a state receives Federal Financial Participation (FFP) for any part of a claim for a Covered Outpatient Drug (COD), that portion of the claim is included in the Medicaid Reimbursed amount. If a state does not receive FFP for any part of a rebate-eligible claim, then the amount of the claim is included in the Non-Medicaid Reimbursed amount.
FAQ ID:91981
SHARE URLWhy Does the "Medicaid Amount Reimbursed" and the "Non-Medicaid Amount Reimbursed" not equal the "Total Amount Reimbursed" in the State Drug Utilization Data (SDUD)?
The sum of the “Medicaid Amount Reimbursed” and the “Non-Medicaid Amount Reimbursed” fields should generally equal the Total Amount Reimbursed on a National Drug Code (NDC) by NDC basis; however, these new fields were implemented beginning with the fourth quarter of 2007 and are optional for the states to report prior to that time. Therefore, for quarters earlier than fourth quarter 2007, there may be some large discrepancies between the Total Amount Reimbursed and the sum of the Medicaid Amount Reimbursed and the Non-Medicaid Amount Reimbursed because the Non-Medicaid Amount Reimbursed is often not present for those earlier quarters. Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.
FAQ ID:91986
SHARE URLIs the amount reimbursed by Medicaid net of rebates or pre-rebate in the State Drug Utilization Data (SDUD)?
Does the State Drug Utilization Data (SDUD) field "Units Reimbursed" represent the number of pills Medicaid paid for a drug that comes in a pill form?
"Units Reimbursed" are the number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state or, for MCO drugs, the number of units dispensed during the Quarter/Year. For more specific information, you may contact either the Drug Manufacturer or State via the contact lists.
FAQ ID:92016
SHARE URLWhen are states required to submit State Drug Utilization Data (SDUD) to the Centers for Medicare & Medicaid (CMS)?
States are required to submit their utilization data to CMS within 60 days of the end of the rebate period.
FAQ ID:92026
SHARE URLHow long does a state have to report State Drug Utilization Data (SDUD) that was not previously reported?
Per section 1927 of the Act, initial submissions of quarterly state utilization data are due to CMS within 60 days of the end of each rebate period. If a state fails to report utilization data in the quarter that it was dispensed, the state must submit initial utilization data for the most recently closed quarter as well as adjustments/corrections to any previously reported utilization data.
FAQ ID:92036
SHARE URLAre all states required to participate in the Medicaid Drug Rebate Program (MDRP)? If not, is there a listing published by Medicaid indicating who is not participating?
Drug coverage under Medicaid is an optional benefit for the states. However, if a state opts to cover prescription drugs in their Medicaid program, they must participate in the MDRP. As part of that participation in the MDRP, states are required to submit quarterly drug utilization data to CMS. All states and the District of Columbia currently participate in the MDRP; therefore, they all submit quarterly drug utilization data to CMS.
FAQ ID:92061
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