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
No. Verification of current board certification is sufficient.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93886
Since the only evidence of eligibility is the self-attestation and claims history, the state would need to take steps to verify the practice characteristics of the physician. This could be done by determining that the physician represents himself in the community as a family practitioner, as evidenced by medical directory listings, billings to other insurers, advertisements, etc.
While we have no objection to the addition of this information to the state plan amendment (SPA), we believe it is more important that the state make providers aware of the audit procedures and requirements as part of the enrollment process.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93891
When there are RVUs for just one site of service the state should use those RVUs. There is no alternate method for calculation.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93896
Providers such as RHCs and Federally Qualified Health Centers (FQHCs) are reimbursed on the basis of an all-inclusive rate under their own Medicaid benefit categories. As specified in the final regulation, only services provided under the physician benefit and billed using a physician fee schedule are eligible for higher payment. In your examples, since the state reimburses the vaccine administration and the hospital codes on a fee-for-service basis and does not pay then all-inclusive rate, those services would be eligible for higher payment if the physician who provides them properly self attests to eligibility. However, services provided by the physician that are reimbursed through the all-inclusive rate would not be eligible.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93901
CMS agrees that 42 CFR 447.205(b)(1) excepts states from the public notice requirements when a change is being made to conform to Medicare reimbursement. However, states must still ensure that providers are properly notified of the requirements for self-attestation and higher payment through provider bulletins or other mechanisms.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93906
No. The only services that qualify are those provided directly by physicians (or by non-physician practitioners that they supervise) who self-attest to an eligible primary care designation and whose attestation is supported by evidence of board certification or claims history. Physicians who do not qualify on their own merits cannot receive higher payment by having an eligible physician bill on their behalf. As previously noted, physicians must accept professional responsibility/liability for the services provided by non-physician practitioners under their supervision.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93911
No. The only codes that are eligible for reimbursement at the Medicare rate as specified under the final rule are those eligible codes that are identified under the Medicaid state plan. Additional E&M or vaccination administration codes that are being “covered” by a health plan but that are not identified in the state plan cannot be reflected in the rates.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93916
States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in some states, this sample will include both fee-for-service (FFS) and managed care providers.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93921
The state has two options: (1) it may claim this cost as an administrative expense of the Medicaid program; or, (2) it may require physicians to provide this documentation when they self-attest.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Provider Payments
FAQ ID: 93926
Effective January 1, 2014, MAGI eligibility rules will be used to determine eligibility for nonelderly, nondisabled eligibility groups. The transition to MAGI also involves converting current net income eligibility standards to MAGI standards. MAGI rules apply regardless of whether a state adopts the new adult eligibility group. The December 28, 2012 Modified Adjusted Gross Income (MAGI) conversion guidance sets out options for a state to use a standardized MAGI conversion methodology (using Survey of Income and Program Participation (SIPP) data or with state data) or to propose an alternative methodology for converting to MAGI.
There are two potential ways of using the standardized MAGI conversion methodology:
- States may choose to have CMS calculate the converted income levels for eligibility groups requiring conversion using state-adjusted data from the Census Bureau's SIPP; or
- States may choose to use their own data as the source for applying the standardized conversion methodology.
For each eligibility group income level that needs to be converted, under the standardized MAGI conversion methodology, individuals whose net income is within 25 percentage points of the FPL below the current income standards will be selected (for example, if the current standard is 80 percent of the FPL, the analysis will include people with incomes between 55 and 80 percent FPL). The next step is to calculate disregards as a percent of FPL for each selected individual. The resulting average disregard amount as a percent of FPL is added to the current net income standard to get the converted standard.
For example, if the average disregard is 8 percent FPL, the converted standard would be 88 percent FPL. This basic process is the same regardless of whether SIPP data or state data is used.
Alternatively, states have the option to propose their own method, subject to approval by CMS. States are asked to provide a statement of intent by February 15, 2013 and must submit their MAGI conversion plans by April 30.
Supplemental Links:
Date: February 28, 2013
Topics:
Affordable Care Act
Subtopics:
MAGI Conversions and Standards
FAQ ID: 93931