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A Medicaid and CHIP state plan is an agreement between a state and the Federal government describing how that state administers its Medicaid and CHIP programs. It gives an assurance that a state will abide by Federal rules and may claim Federal matching funds for its program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative activities that are underway in the state.
When a state is planning to make a change to its program policies or operational approach, states send state plan amendments (SPAs) to the Centers for Medicare & Medicaid Services (CMS) for review and approval. States also submit SPAs to request permissible program changes, make corrections, or update their Medicaid or CHIP state plan with new information.
Persons with disabilities having problems accessing the SPA PDF files may call 410-786-0429 for assistance.
Summary: This SPA amends the State plan pages to reimburse providers based on a submitted invoice price for a drug’s ingredient cost when other pricing benchmarks are unavailable.
Summary: CMS is approving this time-limited state plan amendment to respond to the COVID-19 national emergency. The purpose of this amendment is to waive any signature requirements for the dispensing of drugs during the COVID-19 Public Health Emergency.
Summary: CMS is approving this time-limited state plan amendment to respond to the COVID-19 national emergency. The purpose of this amendment is to waive any signature requirements for the dispensing of drugs during the Public Health Emergency.
Summary: Effective January 1, 2021, this amendment eliminates the monthly six prescription limit and one dollar per prescription (or refill) copayment.
Summary: This time-limited state plan amendment responds to the COVID-19 national emergency. The purpose of this amendment is to cover the new COVID-19 testing group; expand eligibility by disregarding income up to 138% FPL for certain individuals; expand Hospital Presumptive Eligibility (HPE) to certain groups and expand the number of HPE periods in a 12-month period to two HPE periods for certain groups; suspend cost-sharing for COVID-19 testing and treatment services; suspend enrollment fees, premiums, and similar charges for certain groups; allow physicians and other licensed practitioners (OLPs) to order Medicaid home health services; modify the rehabilitative services benefit in the Drug Medi-Cal State Plan to expand the uses for individual counseling visits; remove utilization controls on covered benefits to the extent such limits can’t be exceeded based on medical necessity; use telehealth by modifying the face-to-face requirement for State Plan benefits/services to be provided via all forms of telehealth, regardless of originating or distant site; adjust day supply or quantity limits for covered outpatient drugs; include non-legend acetaminophen-containing drugs, non-legend cough, and cold drugs that are covered outpatient drugs in the pharmacy benefit; and allow prior authorizations for medications to be expanded by automatic renewal without clinical review, or time/quantity extensions. This amendment also will add COVID-19 diagnostic tests and corresponding payment increases for these tests up to the corresponding Medicare level; increase current per diem rates by 10 percent to Nursing Facilities and ICF/DDs; modify the face-to-face requirement for virtual communications and allow for reimbursement as appropriate using HCPCS code G0071 at the Medicare rate; suspend requirements for face-to-face contact in the Drug Medi-Cal state plan program and treat non-face-to-face contacts as equivalent to face-to-face contacts; and pay for ancillary costs for Drug Medi-Cal services only.
Other temporary payment changes will allow the In-Home Supportive Services (IHSS) Individual Provider Rate to include payment for paid time off of IHSS providers related to COVID-19 sick leave benefits for a limited time period; and update the State-approved county governmental, contracted, and private individual provider rates fee schedule to reflect the additional sick leave mandated pursuant to the Emergency Paid Sick Leave Act. For the Drug Medi-Cal and Specialty Mental Health programs in the state plan, the amendment will increase interim rates by 100%, and remove charges as a limit in cost settlement; exempt the clinical lab COVID-19 testing procedure codes from the 10 percent payment reduction mandated by state law; and add Associate Marriage and Family Therapists/Associate Clinical Social Workers (AMFTs/ACSWs) as billable provider types in FQHCs/RHCs.
Summary: Comply with the Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act
