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Featured Questions
How far back can state Medicaid agencies go in requesting eligibility and coverage information from health ...- The Deficit Reduction Act of 2005 (DRA) requires states to have laws in effect that require health insurers to honor ... (more)
The Deficit Reduction Act of 2005 (DRA) requires states to have laws in effect that require health insurers to honor claims submitted by the Medicaid agency within three years of the date of service.
(FAQ10538)
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What is Medicare’s general timely filing period?- Sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the Social Security Act, as well as the Medicare regulations at... (more)
Sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the Social Security Act, as well as the Medicare regulations at 42 CFR section 424.44, specify the time limits for filing Medicare Fee-For-Service (FFS)--Part A and Part B--claims.
The Affordable Care Act reduced the maximum period for submission of all Medicare FFS claims to no more than 12 months (one calendar year) after the date services were furnished. This time limit policy for claims submission became effective for services furnished on or after January 1, 2010. In addition, claims for services furnished prior to January 1, 2010, had to be submitted no later than December 31, 2010. Section 6404 of the Affordable Care Act also mandated that CMS may specify exceptions to the one calendar year time limit for filing Medicare claims.
(FAQ10562)
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What is the responsibility of liable third parties regarding health insurers’ denials of Medicaid claims ...- Under section 1902(a)(25)(H) of the Social Security Act (the Act) before passage of the Deficit Reduction Act of 2005... (more)
Under section 1902(a)(25)(H) of the Social Security Act (the Act) before passage of the Deficit Reduction Act of 2005 (DRA), states were required to have laws in effect that to the extent Medicaid payment was made, the state was considered to have acquired the rights of the Medicaid beneficiary to reimbursement by any other party that was liable for payment. However, payers sometimes deny Medicaid claims based on procedural requirements. Section 1902(a)(25)(I) of the Act, added by the DRA, strengthens the statute by requiring states to enact laws that require health insurers:
(1) To accept the state’s right of recovery and the assignment to the state of the right of a Medicaid beneficiary or other entity to payment from such party for an item or service for which Medicaid has made payment; and,
(2) To process and, if appropriate, pay the claim for reimbursement from Medicaid to the same extent that the plan would have been liable had the plan’s card been used for billing at the “point of sale” (POS).
Specifically, the state should pass laws which require an insurer to agree not to deny claims submitted by the state on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation of coverage at the POS that is the basis of the claim.
Whether a plan provision affecting payment for an item or service is solely procedural in nature or whether it defines or limits the covered benefits must be determined on a case-by-case basis.
Note that nothing in the DRA negates the state’s responsibility to provide proper documentation when submitting claims to the health insurer so that the insurer can determine that a covered service for which the insurer is liable was provided.
(FAQ10550)
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How long do states have to submit a claim for reimbursement to health insurers?- Section 1902(a)(25)(I) of the Social Security Act requires states to have laws in effect that require health insurers... (more)
Section 1902(a)(25)(I) of the Social Security Act requires states to have laws in effect that require health insurers to make payment as long as the claim is submitted by the state within three years from the date on which the item or service was furnished.
Some health insurers currently deny claims submitted by Medicaid if they are not filed within a prescribed time limit, which is applied to plan beneficiaries and providers (e.g., a plan might require beneficiaries and providers to submit claims within 30 days from date of service). If the state Medicaid agency is unable to ascertain the existence of the third party coverage and submit a claim within the time limit, the insurer may attempt to avoid liability.
Any action by the state to enforce its rights with respect to such claim must be commenced within six years of the state’s submission of such claim. Health insurers also must respond to any inquiry by a state regarding claims submitted within three years from the date on which the item or service was furnished.
(FAQ10554)
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What are the exceptions to Medicare’s general timely filing period?- Medicare regulations at 42 CFR section 424.44(b) allow for the following exceptions to the 1 calendar year time limit... (more)
Medicare regulations at 42 CFR section 424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:
(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority.
(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service.
(3) Retroactive Medicare entitlement involving state Medicaid agencies, where a state Medicaid agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished, the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The state Medicaid agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired.
(4) Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier 6 months or more after the date the service was furnished.
(FAQ10564)
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May Medicaid programs bill Medicare directly? - No. States typically do not meet the definition of a covered health care provider, and therefore, are not eligi... (more)
No. States typically do not meet the definition of a covered health care provider, and therefore, are not eligible to receive a National Provider Identifier (NPI) number to enable them to bill Medicare. The NPI is the standard unique identifier for health care providers that CMS adopted in 2007. At that time, Medicare revoked existing billing numbers previously issued to Medicaid agencies and notified Medicare carriers to stop enrolling Medicaid programs as Medicare providers. Only recognized providers and suppliers of services that have an NPI can enroll in Medicare. Medicare will not enroll state Medicaid programs, as they are not direct providers or suppliers of services.
Medicaid may submit claims to health plans on behalf of Medicaid beneficiaries who have assigned their rights to payment from third parties (other than Medicare) to the Medicaid program, under the authority of sections 1912, 1902(a)(25)(H), and 1992(a)(25)(I)(ii) of the Social Security Act. However, Medicaid doesn’t have the same authority to submit claims to Medicare on behalf of a “dually” eligible beneficiary. The rights to Medicare benefits are not assignable; only the Medicare provider and the beneficiary may submit claims to Medicare.
(FAQ10558)
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Are indemnity insurance policies considered to be third party resources for purposes of Medicaid?- Indemnity policies may be considered third party resources if the policies meet certain criteria. Federal Medic... (more)
Indemnity policies may be considered third party resources if the policies meet certain criteria. Federal Medicaid regulations at 42 CFR 433.136 define a third party as “any individual, entity, or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a state plan.” This includes private insurance. Section 433.136 also defines private insurer to include “any commercial insurance company offering health or casualty insurance to individuals or groups (including both experience-related insurance contracts and indemnity contracts).” Private insurers are required to comply with the Deficit Reduction Act of 2005 (DRA) and related state enactments.
Indemnity plans may include a variety of insurance policies such as accident, cancer/specified disease, dental, hospital confinement indemnity, hospital confinement sickness indemnity, hospital intensive care, long-term care, short-term disability, specified health event, and vision. An individualized review of the various policy terms would be necessary to determine if they should be considered a third party resource for purposes of Medicaid. If this review determines that the policy provides for payment of health care items and services, the policy is a third party resource and payments would be assigned to the Medicaid agency.
An indemnity policy may be designed to pay a cash benefit to policyholders, unless the policyholder chooses otherwise. The policy may state that these payments may be used to cover medical expenses or living expenses such as rent, child care, or groceries. However, the insurance company may condition payment upon the occurrence of a medical event. Whenever payments are linked to specific medical events, these payments should be considered third party payments. Thus, the state could seek to recover Medicaid payments from the policy benefits.
Where indemnity policies do not qualify as a third party resource, any payments made to a Medicaid beneficiary may be countable as income for Medicaid eligibility purposes.
(FAQ10530)
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What information are health insurers required to share with state Medicaid agencies?- States enact laws to comply with section 1902(a) (25) (I)(i) of the Social Security Act and must require health insur... (more)
States enact laws to comply with section 1902(a) (25) (I)(i) of the Social Security Act and must require health insurers to provide, upon the request of the state, information to determine during what period Medicaid beneficiaries may be (or may have been) covered by the health insurer and the nature of the coverage that is or was provided.
This information includes, at a minimum, four (4) data elements: the insured’s name, address, group or member ID number, and periods of coverage. State laws determine exactly what information is required to be submitted by the health plans. Health plans are to provide these files to state Medicaid programs so that these programs can determine whether any third party payers are liable for the medical items and services that were, or will be, delivered to a Medicaid beneficiary. In essence, the point of the information gathering is to ensure that Medicaid benefits are paid correctly.
In the case of health insurers who contract with a pharmacy benefit manager (PBM) or other third party administrator (TPA) to administer the plan, states also will need to require that such insurers provide the PBM or TPA with such information as may be necessary to enable that entity to furnish the state with the prescribed data, or deal with such inquiries directly without the aid of their PBM or TPA.
(FAQ10536)
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What are the requirements under the Social Security Act for health insurers to share eligibility informatio...- Section 6035(b) of the Deficit Reduction Act of 2005 (DRA) created a new subparagraph (I) in section 1902(a)(25) of t... (more)
Section 6035(b) of the Deficit Reduction Act of 2005 (DRA) created a new subparagraph (I) in section 1902(a)(25) of the Social Security Act (the Act), that requires states to establish laws that require the production of the information necessary for each state Medicaid agency to determine third party liability for services rendered to Medicaid beneficiaries. Specifically, section 1902(a) (25) (I) (i) of the Act directs states, as a condition of receiving federal financial participation (FFP) for Medicaid, to have laws in effect that require health insurers doing business in their state to provide the state with the requisite information with respect to individuals who are eligible for, or are provided medical assistance, i.e., Medicaid beneficiaries.
States pass their own laws regarding the submission of health insurance information to implement the provisions of the DRA. As with most federal laws that require some action on the part of the state to implement, states have some latitude in determining how best to comply. Since the information would be provided to the state Medicaid agency as required by that state’s laws, it follows that the submission should conform to what is required under that state law. Such requirements would ensure the state Medicaid agency’s access to the information is necessary and sufficient to determine third party liability for care provided to Medicaid beneficiaries.
(FAQ10534)
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Does a health plan’s submission of information from its full eligibility file, for the purpose of matchin...- State laws determine what information is required of the health plans. A health plan’s disclosure and use of ... (more)
State laws determine what information is required of the health plans. A health plan’s disclosure and use of information that is required to be submitted under state law – such as, information from insurer eligibility files sufficient to determine during what period any individual may be, or have been, covered by a health insurer and the nature of the coverage that is or was provided by the health insurer — is consistent with the HIPAA privacy provisions.
Under HIPAA, both the state Medicaid agency and most health insurers are covered entities and must comply with the HIPAA Privacy Rule in 45 CFR Part 160 and Part 164, Subparts A and E. In their capacities as covered entities under HIPAA, the state Medicaid agency and health insurers are restricted from using and disclosing protected health information (PHI), as that term is defined in 45 CFR section 160.103, other than as permitted or required by the HIPAA Privacy Rule. However, as relevant here:
(1) A covered entity may use or disclose PHI to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. (45 CFR 164.512(a)(1)) Under this provision, each covered entity must be limited to disclosing or using only the PHI necessary to meet the requirements of the law that compels the use or disclosure. Anything required to be disclosed by a law can be disclosed without violating HIPAA under the “required by law” provisions. Therefore, health insurers may disclose data elements in addition to the four minimum data elements, up to and including submission of an entire insurer eligibility file, to the extent such information is required to be submitted by state law. (45 CFR 164.512(a))
(2) Separately, a covered entity may use or disclose PHI, without the consent of an individual, for payment activities, including to facilitate payment. (45 CFR 164.502(a)(1) and 164.506) Under HIPAA, the term payment includes activities undertaken by a health plan to determine or fulfill its responsibility for coverage and provision of benefits under the health plan. These activities include determinations of eligibility or coverage, adjudication or subrogation of health benefits claims, and collection activities. (45 CFR 164.501) To the extent plans are releasing this information to the Medicaid program for payment purposes; this is a separate basis for disclosure under HIPAA.
(3) The HIPAA Privacy Rule generally requires covered entities to take reasonable steps to limit the use and disclosure of PHI to the minimum necessary to accomplish the intended purpose. (45 CFR 164.502(b)(1)) However, among other limited exceptions, the minimum necessary requirements do not apply to uses or disclosures that are required by law under 45 CFR 164.512(a).
(FAQ10542)
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May state Medicaid agencies request information on subscribers and dependents covered in other states?- Yes. There is a significant amount of third party coverage derived from health plans licensed in a different st... (more)
Yes. There is a significant amount of third party coverage derived from health plans licensed in a different state than where the Medicaid beneficiary resides. This can commonly happen when the policyholder works in one state and lives in another state. For example, there may be policyholders who are enrolled in Medicaid coverage in Maryland, or have dependents that are enrolled, who work in Delaware, the District of Columbia, Pennsylvania, Virginia, or West Virginia and also have coverage through their employer in that state. This highlights the need for Medicaid agencies to obtain plan eligibility information from contiguous states in addition to collecting information in their respective state.
Another example is when Medicaid-eligible children are covered by the insurance plan of non-custodial parents who live in a different state than their child(ren). This example is not limited to contiguous states because non-custodial parents could reside in any state in the country. Depending on the size, it may be beneficial for the state to obtain the plan’s entire eligibility file. The specific geographical areas to be included in the data exchange should be negotiated with the plans. We recommend use of a Trading Partner Agreement in the exchange of electronic data.
Finally, section 1902(a)(25)(I)(i) of the Social Security Act directs states, as a condition of receiving federal financial participation (FFP) for Medicaid, to have laws in effect that require health insurers doing business in their state to provide the state with the requisite information with respect to individuals who are eligible for, or are provided medical assistance, i.e., Medicaid beneficiaries. State law cannot reach beyond the entities that are “doing business” in their states.
(FAQ10544)
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What are the parameters of the Social Security Act related to the liability of health insurers and other th...- The Social Security Act (the Act) generally requires health insurers and other third parties that are legally liable ... (more)
The Social Security Act (the Act) generally requires health insurers and other third parties that are legally liable to pay for health care services received by Medicaid beneficiaries to pay for the services that are primary to Medicaid. However, state Medicaid agencies might mistakenly pay claims for which a third party may be liable, because they are not aware of the existence of other coverage.
The Deficit Reduction Act of 2005 (DRA) made a number of changes to title XIX of the Social Security Act intended to strengthen state Medicaid programs’ ability to identify and collect from third party payers that are legally responsible to pay claims primary to Medicaid.
Specifically, section 6035 of the DRA amended section 1902(a) (25) of the Act:
(1) To clarify which specific entities are considered “third parties” and “health insurers” that may be liable for payment and that cannot discriminate against individuals on the basis of Medicaid eligibility; and,
(2) To require that states pass laws requiring health insurers:
(a) To provide the state with the coverage, eligibility, and claims data needed by the state to identify potentially liable third parties, including, at a minimum, name, address, and ID number;
(b) To honor the assignment to the state of a Medicaid beneficiary’s right to payment by insurers for health care items or services; and,
(c) Not to deny such assignment or refuse to pay claims submitted by Medicaid based on procedural reasons (e.g., the failure of the beneficiary to present his/her insurance card at the point of sale, or the state’s failure to submit an electronic, as opposed to a paper, claim).
(FAQ10520)
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Can Medicaid Managed Care Organizations (MCOs) use a contractor to complete data matches with health i...- Yes. State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegat... (more)
Yes. State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs to perform third party liability TPL discovery and recovery activities, including data matches as required by the Deficit Reduction Act of 2005 (DRA). The Medicaid program may authorize the MCO to use a contractor to complete these activities. The contract language between the state Medicaid agency and the MCO dictates the terms and conditions under which the MCO assumes TPL responsibility. Generally, any TPL administration and performance standards for the MCO will be set by the state and should be accompanied by state oversight.
When TPL responsibilities are delegated to an MCO, third parties are required to treat the MCO as if it were the state Medicaid agency, including:
(1) Providing access to third party eligibility and claims data to identify individuals with third party coverage;
(2) Adhering to the assignment of rights from the state to the MCO of a Medicaid beneficiary’s right to payment by such insurers for health care items or services; and,
(3) Refraining from denying payment of claims submitted by the MCO for procedural reasons.
Third parties may request verification from the state Medicaid agency that the MCO or its contractor is working on behalf of the agency and the scope of the delegated work.
(FAQ10548)
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How are “third parties” defined in the Social Security Act (The Act) and what changes did the Deficit R...- Section 1902(a)(25)(A) of the Act requires states to take all reasonable measures to ascertain the legal liability of... (more)
Section 1902(a)(25)(A) of the Act requires states to take all reasonable measures to ascertain the legal liability of “third parties” for health care items and services provided to Medicaid beneficiaries. The DRA did not change the definition of “third parties,” but rather clarified the entities subject to the provisions of section 1902(a) (25) (A) and (G) of the Act. Section 6035(a) of the DRA amended section 1902(a)(25)(A) of the Act to clarify that the “third parties” subject to the provisions of 1902(a)(25) include: (1) self-insured plans, (2) pharmacy benefits managers (PBM), and (3) “other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service”, including workers’ compensation, automobile insurance, and liability insurance plans. The DRA also replaced reference to “a health maintenance organization” with “a managed care organization” (MCO) in identifying the types of third parties to which the provisions of section 1902(a) (25) apply.
Section 1902(a) (25) (G) of the Act prohibits health insurers from taking an individual’s Medicaid status into account in enrollment or payment decisions.
(FAQ10522)
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How should a state that has a section 1915(c) home and community-based serviceswaiver that is limited to EP...- The ASD-related services should be provided through the Medicaid state plan for theEPSDT-eligible individuals, rathe... (more)
- The ASD-related services should be provided through the Medicaid state plan for the
EPSDT-eligible individuals, rather than the 1915(c) waiver. CMS will work with states to
ensure that such services are able to be made available under the state plan. Accordingly,
CMS with also work with states to remove the service from the 1915(c) home and
community-based services waiver at the next amendment or renewal, whichever comes
first.
(FAQ10730)
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Are Pharmacy Benefits Managers (PBMs) and Third Party Administrators (TPAs) considered to be third party re...- Yes. PBMs and TPAs are considered to be “third parties,” as clarified in section 6035(a) of the Deficit Red... (more)
Yes. PBMs and TPAs are considered to be “third parties,” as clarified in section 6035(a) of the Deficit Reduction Act of 2005 (DRA)'s amendment of section 1902(a)(25)(A) of the Social Security Act.
PBMs, TPAs, and similar entities may not have financial liability for actual payment of claims, depending on the nature and extent of services to be performed for the health insurer, as specified in the contract. However, if the PBM or TPA performs claims review and payment authorization for another third party, the PBM or TPA is expected to provide information to the Medicaid program, so the program can determine which party is the primary payer, for the purpose of coordinating benefits for the Medicaid beneficiary.
State law enacted to implement section 6035(a) of the DRA must require the health insurer that contracts with a PBM, TPA, or other such entity to administer the plan to provide the contracted entity with such information as may be necessary to enable that entity to furnish the state with information about when Medicaid beneficiaries may be (or may have been) covered by the health insurer, the nature of the coverage, and other necessary information.
(FAQ10526)
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How does section 1902(a) (25) of the Social Security Act (the Act) define “health insurers”?- Section 1902(a) (25) (I) of the Act defines “health insurers” to include self-insured plans, group health plans (... (more)
Section 1902(a) (25) (I) of the Act defines “health insurers” to include self-insured plans, group health plans (as defined in section 607(l) of the Employee Retirement Income Security Act of 1974 (ERISA)), service benefit plans, managed care organizations (MCOs), pharmacy benefit managers (PBMs), and “other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.” Workers’ compensation, automobile insurance, and liability insurance plans all are included within the definition of “health insurers” for purposes of this section and the requisite state laws which must be enacted pursuant to it.
The CMS interprets “other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim” to include:
(1) Prepaid Inpatient Health Plans (PIHPs) and Prepaid Ambulatory Health Plans (PAHPs). For purposes of Medicaid managed care, PIHPs and PAHPs are entities that contract with the state to deliver Medicaid-covered services; in that context, they would also be considered “other parties that are, by contract, legally responsible for payment of a claim for a health care item or service;” and,
(2) Such entities as third party administrators (TPAs), fiscal intermediaries, and managed care contractors, which administer benefits on behalf of the risk-bearing plan sponsor (e.g., an employer with a self-insured health plan). CMS recognizes that entities such as PBMs and TPAs do not necessarily have ultimate financial liability, but, to the extent that they are required, by contract or otherwise, to review claims and authorize payment by the plan sponsor, they are included within the definition of “third party” and “health insurer” for purposes of section 1902(a) (25) of the Act.
Nothing in revisions to the Social Security Act made by the Deficit Reduction Act of 2005 (DRA) imposes new liability to pay claims on entities that do not otherwise bear such liability. Nor does section 1902(a) (25) of the Act negate any right of indemnification against a plan sponsor or other entity with ultimate liability for health care claims by a contracting party that pays the claims.
(FAQ10524)
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Is TRICARE subject to the minimum 3-year timely filing period, established in section 6035 of the Deficit R...- No. Based upon federal authority set forth at 10 U.S.C. section 1103, Congress explicitly provided for preemption ... (more)
- No. Based upon federal authority set forth at 10 U.S.C. section 1103, Congress explicitly provided for preemption of state and local laws pertaining to health care financing methods for a contract entered into for medical and/or dental care, under Chapter 55 of the Armed Forces Title of the U.S. Code, by the Secretary of Defense or administering Department of Defense secretaries. The preemption applies to contracts entered into for the purpose of administering TRICARE. Thus, it is the position of the Department of Defense that TRICARE’s 1-year timely filing limit is not superseded by the 3-year limit established in the DRA for health insurers who are regulated by the states, and that TRICARE is exempt, not only from the DRA timely filing requirements, but from the DRA requirements altogether.
(FAQ10566)
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Do states need to submit a Medicaid state plan amendment (SPA) to offer benefits toindividuals with Autism ...- In order to have services reimbursed under the Federal Medicaid program, a service mustmeet the definition of a cove... (more)
- In order to have services reimbursed under the Federal Medicaid program, a service must
meet the definition of a coverable service under section 1905(a) of the Social Security
Act. Treatment for ASD is not specifically referenced as a section 1905(a) service.
However, some treatment modalities, or components of such treatment modalities, are
within the scope of the federal Medicaid program under the following service categories:
section 1905(a)(6) Other Licensed Practitioner (OLP), section 1905(a)(13) Preventive
Services, and section 1905(a)(11) Therapies :. States may provide services to address ASD
under each of these benefit categories. States will need to determine what, if any, steps
are needed to implement this policy clarification. In keeping with the role of the Medicaid
state plan as a comprehensive written statement of the nature and scope of services
available under the state’s Medicaid program, a SPA is strongly encouraged to articulate
the state’s menu of services for ASD treatment.
(FAQ10728)
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How may state Medicaid agencies use the data obtained from the third party insurers?- State Medicaid agencies and their business associates can use the data obtained pursuant to the process established unde... (more)
- State Medicaid agencies and their business associates can use the data obtained pursuant to the process established under section 1902(a)(25)(I) of the Scial Security Act and applicable state laws, as permitted or required by law. This should include the coordination of payments for services covered under the Medicaid state plan and actions to ensure that correct payment amounts are made under the Medicaid program and that mistaken payments are recovered. If the appropriate legal relationships are established (e.g., business associate agreements under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)), we expect that the data could be released to entities working under contract with a state agency for use in activities such as claims adjudication activities, or for the purpose of recovering improper Medicaid payments. State Medicaid agencies must have procedures in place to ensure that the privacy of individuals is appropriately protected, and that information concerning applicants and beneficiaries is protected in accordance with the requirements of 42 CFR Part 431 Subpart F and the regulations at 45 CFR Parts 160 and 164, which were promulgated under HIPAA and Health Information Technology for Economic and Clinical Health (HITECH) Act.
(FAQ10540)
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Is Medicare subject to the minimum 3-year timely filing period established in section 6035 of the Deficit R...- No. The DRA limit applies to health insurers, defined in section 1902(a)(25)(A) of the Social Security Act, ... (more)
- No. The DRA limit applies to health insurers, defined in section 1902(a)(25)(A) of the Social Security Act, that are regulated by the states. Medicare Parts A and B are not subject to state regulation, as they do not need to be licensed to do business in the states. State law requiring health insurers to honor claims submitted within the timely filing period established by the state (minimum of three years) would apply to Medicare Part C and D plans.
(FAQ10560)
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Are health plans permitted to require a National Provider Identifier (NPI) for transactions with Medicaid p...- No. States typically do not meet the definition of a covered health care provider under 45 CFR 160.103, and the... (more)
No. States typically do not meet the definition of a covered health care provider under 45 CFR 160.103, and therefore, are not eligible to receive an NPI. If states encounter situations where plans are requiring them to submit an NPI, they can submit a formal complaint to the Office of E-Health Standards and Services (OESS) in CMS by using the online Administrative Simplification Enforcement Tool (ASET). ASET allows individuals or organizations to electronically file a complaint against an entity whose actions they believe violate an Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
States may submit a formal complaint electronically at: https://htct.hhs.gov/aset/.
ASET users are required to register with OESS and create a user identification name and password. States also may submit a paper complaint. The form is available at: www.cms.hhs.gov/Enforcement/Downloads/HIPAANon-PrivacyComplaintForm.pdf.
(FAQ10552)
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Are states precluded from having laws that require third parties to accept claims beyond the 3-year filing ...- No. Section 1902(a)(25)(I)(iv) of the Social Security Act requires states to pass laws that would require health i... (more)
- No. Section 1902(a)(25)(I)(iv) of the Social Security Act requires states to pass laws that would require health insurers to accept claims submitted by the state within the 3-year period beginning with the date on which the item or service was furnished. States are not precluded from having laws or regulations that would require insurers to accept claims for a period of time longer than three years.
(FAQ10556)
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May state Medicaid agencies use contractors to complete data matches with health insurers?- Yes. State Medicaid programs may enter into data matching agreements directly with third parties or may obtain the se... (more)
Yes. State Medicaid programs may enter into data matching agreements directly with third parties or may obtain the services of a contractor to complete the required matches. Such arrangements should comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA)’s “Business Associate” requirements, where applicable. When the state Medicaid program chooses to use a contractor to complete data matches, including matches as required by the Deficit Reduction Act of 2005 (DRA), the program delegates its authority to obtain the desired information from third parties to the contractor.
Third parties should generally treat a request from the contractor as a request from the state Medicaid agency. Third parties may request verification from the state Medicaid agency that the contractor is working on behalf of the agency and the scope of the delegated work.
Medicaid MCOs and TPL
(FAQ10546)
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How should a state that has a section 1915(c) home and community-based serviceswaiver that includes individ...- The ASD-related services for EPSDT eligible individuals (under age 21) must be provided under the Medicaid state plan an... (more)
- The ASD-related services for EPSDT eligible individuals (under age 21) must be provided under the Medicaid state plan and not under the 1915(c) waiver. When the state submits the home and community-based services waiver for renewal or amendment, the state should include a restriction under the ‘limits’ section for that specific service indicating that EPSDT-aged individuals are excluded as the services are fully covered in the state plan. ASD-related services for individuals over age 21 may continue to be provided under the 1915(c) waiver.
(FAQ10732)
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Has CMS mandated Applied Behavior Analysis (ABA) services for children under 21 with Autism Spectrum ...- No. Applied Behavior Analysis (ABA) is one treatment modality for ASD. CMS is not endorsing or requiring any particular ... (more)
- No. Applied Behavior Analysis (ABA) is one treatment modality for ASD. CMS is not endorsing or requiring any particular treatment modality for ASD. State Medicaid agencies are responsible for determining what services are medically necessary for eligible individuals. States are expected to adhere to long-standing EPSDT obligations for individuals from birth to age 21, including providing medically necessary services available for the treatment of ASD.
(FAQ10724)
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When will CMS begin to assess state compliance with coverage requirements for children with Autism Spectrum...- There is no specific time frame for CMS review of state practices in this area. The CMCS Informational Bulletin released... (more)
- There is no specific time frame for CMS review of state practices in this area. The CMCS Informational Bulletin released July 7, 2014 (see http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf), related to Autism Spectrum Disorder discusses the obligations under the Medicaid statute and regulations that are already in effect. However, CMS recognizes that states may not have focused on the application of these requirements in this area. As a result, a state may need time to review its current program policies to determine if changes are needed to existing state regulations and/or policy to ensure compliance. States may also want to confer with the stakeholder community for public input on the benefit design of autism services for children. CMS believes states should complete this work expeditiously and should not delay or deny provision of medically necessary services. CMS is available to provide technical assistance to states to ensure the availability of services that children may need.
(FAQ10726)
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Who is eligible for BHP?- Individuals are eligible for BHP coverage if they:• Are state residents and either a citizen, or a lawfully p... (more)
- Individuals are eligible for BHP coverage if they:
• Are state residents and either a citizen, or a lawfully present non-citizen;
• Have household income (Modified Adjusted Gross Income/MAGI) between 133 and 200 percent of the federal poverty level (FPL) or, in the case of individuals who are lawfully present non-citizens, are ineligible for Medicaid due to such non-citizen status, and have household income that does not exceed 200 percent of the FPL;
• Are 64 years of age or younger;
• Are not otherwise eligible for minimum essential coverage, including through Medicaid, CHIP or affordable employer sponsored insurance; and
• Are not incarcerated, other than during a period pending disposition of charges.
(FAQ9970)
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What is the Basic Health Program (BHP)?- The Basic Health Program (BHP) is an optional health benefits coverage program for low-income individuals (defined as in... (more)
- The Basic Health Program (BHP) is an optional health benefits coverage program for low-income individuals (defined as individuals with incomes between 133 and 200 percent of the Federal poverty level) who would otherwise be eligible to purchase coverage through the state’s Health Insurance Marketplace (Marketplace). In states that establish a BHP, eligible individuals would instead have the opportunity to enroll in a standard health plan through the BHP. Coverage through a BHP standard health plan would complement and coordinate with enrollment in a qualified health plan (QHP) through the Marketplace, as well as with enrollment in Medicaid, and the Children’s Health Insurance Program (CHIP).
(FAQ9964)
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Can individuals with disabilities and other long-term care needs (who are not eligible in the mandatory gro...- Yes. People with disabilities or who need long term care services and supports may qualify under the new adult grou... (more)
Yes. People with disabilities or who need long term care services and supports may qualify under the new adult group in 2014 if they meet the MAGI-based eligibility standards for that group. In addition, under the final eligibility and enrollment rule, eligibility for the new adult group based on MAGI does not preclude eligibility for coverage under an optional group that might be otherwise excepted from MAGI methods. Individuals with MAGI-based income up to 133% of the federal poverty level who meet the criteria for the adult group but who need long-term services and supports, can choose to enroll in an optional group that better meets their needs, and they can move from the adult group to the optional eligibility group at any time, if eligible. Individuals found eligible for the new adult group based on MAGI, but who appear on the application to be potentially eligible for Medicaid on a basis other than MAGI, will be offered a more thorough eligibility determination so that they can have this option.
(FAQ9410)
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With respect to MAGI conversion, how will the 5% disregard be applied? - The Affordable Care Act established an income disregard equal to five percentage points of the FPL disregard “for... (more)
The Affordable Care Act established an income disregard equal to five percentage points of the FPL disregard “for the purposes of determining income eligibility” for individuals whose eligibility is based on MAGI. In our final rule issued July 15, 2013, we provide that the disregard is applied to the income calculation of individuals only to the extent that the disregard matters for the purposes of determining eligibility for Medicaid or CHIP under MAGI-based rules—that is, those for whom the application of the disregard means the difference between being eligible for Medicaid or CHIP and being ineligible. The final rule is available at http://www.gpo.gov/fdsys/pkg/FR-2013-07-15/pdf/2013-16271.pdf
The disregard matters for purposes of determining Medicaid or CHIP eligibility only in cases where individuals have MAGI-based income that is above the highest applicable income standard under the program (Medicaid or CHIP), but would be within that income standard if the disregard were applied. This is the case only when the MAGI-based income is no higher than five percent of the FPL higher than that income standard. The disregard would not be applied for a determination of the particular eligibility group in which the individual qualifies, but only for overall eligibility for Medicaid or CHIP. We understand that this policy changes how disregards have been applied in the past, but believe this policy should be administratively simple to apply, for example, by applying the disregard at the point before a decision of ineligibility based on income would otherwise be made. This also ensures that the disregard does not reduce the “newly eligible” population for whom the increased federal matching rate is available.
For example, in a state that extends coverage to the new adult group, if a parent applied and has MAGI-based income within five percentage points of the FPL above the net income standard for the mandatory parent/caretaker relative group, the disregard would not apply because the disregard would not be needed for eligibility. The parent could be made eligible in the adult group instead. In that same state, if a parent applied with MAGI income within five percentage points of the FPL above the net income standard for the adult group (133% FPL), the five percent disregard would be applied to ensure that the parent could obtain eligibility in Medicaid and the parent would be made eligible in the adult group.
(FAQ9486)
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What is premium assistance in Medicaid?- The Medicaid statute provides several options for states to pay premiums for adults and children to purchase covera... (more)
The Medicaid statute provides several options for states to pay premiums for adults and children to purchase coverage through private group health plans, and in some case individual plans; in most cases, the statute conditions such arrangements on a determination that they are “cost effective.” Cost effective generally means that Medicaid’s premium payment to private plans plus the cost of additional services and cost sharing assistance that would be required would be comparable to what it would otherwise pay for the same services. Similar provisions also apply in the Children’s Health Insurance Program (CHIP). Under all these arrangements, beneficiaries remain Medicaid beneficiaries and continue to be entitled to all benefits and cost-sharing protections. States must have mechanisms in place to “wrap-around” private coverage to the extent that benefits are less and cost sharing requirements are greater than those in Medicaid. In addition under the statutory options in the individual market beneficiaries must be able to choose an alternative to private insurance to receive Medicaid benefits.
A state may pursue premium assistance as a state plan option without a waiver.
(FAQ9502)
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What are some examples of income that is not considered taxable, and therefore excluded from MAGI?- Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Veterans’ disability, Workers’ Co... (more)
- Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Veterans’ disability, Workers’ Compensation, child support, federal tax credits, and cash assistance are common types of income that are not taxable.
(FAQ9422)
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Who should be contacted with questions?- If there are questions or problems related to the system/website, please contact the MACPro Help Des... (more)
- If there are questions or problems related to the system/website, please contact the MACPro Help Desk staff via email to MACPro_HelpDesk@cms.hhs.gov. If there are questions regarding the quality measure content or reporting please contact MAC Quality TA via the contact link at the bottom of the screen or by email to MACQualityTA@cms.hhs.gov
(FAQ14561)
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What does it mean for an individual to withdraw their Medicaid application in order to receive a determinat...- In a State where the Marketplace makes Medicaid and CHIP eligibility assessments, but not eligibility determination... (more)
In a State where the Marketplace makes Medicaid and CHIP eligibility assessments, but not eligibility determinations, there are certain requirements that the Marketplace must follow (found at 42 CFR 155.302(b)) in order to ensure a smooth transition between programs. When an eligibility assessment reveals that an applicant is potentially eligible for Medicaid or CHIP, the Exchange must transmit the individual’s electronic account to the Medicaid or CHIP agency for completion of the eligibility determination.
However, when an eligibility assessment reveals that an applicant does not appear to be Medicaid or CHIP-eligible, the Exchange does not have the authority to deny Medicaid/CHIP eligibility (because that is not the arrangement in that State). The Exchange has the responsibility to notify applicants that they do not appear to be Medicaid/CHIP-eligible and provide them with the opportunity to either seek a formal Medicaid eligibility determination (which would delay the eligibility determination for an APTC), or to withdraw their application for Medicaid/CHIP and receive a determination for an APTC and a cost-sharing reduction (section 155.305(b)(4)). We will address in further guidance how the withdrawal will be addressed in the case of an appeal of an APTC decision.
(FAQ9368)
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How do the home and community-based settings requirements impact assisted living facilities?- The requirements for home and community-based settings set forth in the final rule apply to all settings where individua... (more)
- The requirements for home and community-based settings set forth in the final rule apply to all settings where individuals receive HCBS, including assisted living facilities. The rule also applies additional requirements for provider owned or controlled settings. In response to public comments, several provisions in the Notice of Proposed Rulemaking (NPRM) relevant to assisted living facilities were modified. For more detail, please refer to the HCBS Settings fact sheet at http://www.medicaid.gov/HCBS.
(FAQ9806)
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What is MAGI and how is it different than the way states calculate eligibility today? - It’s a new, simpler way to determine eligibility for Medicaid and CHIP.
The Affordab... (more)
It’s a new, simpler way to determine eligibility for Medicaid and CHIP.
The Affordable Care Act provides a new simplified method for calculating income eligibility for Medicaid, CHIP and financial assistance available through the health insurance Marketplace. This new method calculates eligibility for all programs based on what is called modified adjusted gross income (MAGI). By using one set of income eligibility rules across all insurance affordability programs, the new law makes it easier for people to apply for health coverage through one application and enroll in the appropriate program. MAGI will replace the current process for calculating Medicaid eligibility that is in place today, which uses income deductions (known as “disregards”) that are different in each state and often differ by eligibility group.
(FAQ9448)
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When an individual is eligible for Medicaid and receives a level of care assessment in order to qualify for...- No. The 75% match for eligibility is limited by statute to activities directly related to the eligibility determin... (more)
- No. The 75% match for eligibility is limited by statute to activities directly related to the eligibility determination; a level of care assessment is not directly related to the eligibility determination.
(FAQ9296)
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What if an account contains an out of state address?- Applicants can apply for whatever state they choose. Sometimes someone will want to file an application for a state they... (more)
- Applicants can apply for whatever state they choose. Sometimes someone will want to file an application for a state they don't currently live in. For example, if they are temporarily residing outside the state or have a family member or tax dependent that needs coverage who lives there. When an applicant applies on the Federally Facilitated Marketplace (FFM), they provide their home address and that information is used to validate the eligibility criteria of state residency during the eligibility determination process. If an applicant does not indicate they have a home address in the state they are applying to, and they do not indicate they are temporarily absent from the state, they will be denied Medicaid, CHIP and APTC for that state in accordance with state and federal rules. However, an applicant can always request a full determination, and in doing so, the account is transferred to the state indicated. In order to respond, the state will need to verify residency, and approve or deny Medicaid as applicable.
(FAQ9536)
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What does the Five-Year Period for Certain Demonstration Projects and Waivers provision of the final rule a...- In accordance with section 2601 of the Affordable Care Act, states have the option to request, subject to the appr... (more)
- In accordance with section 2601 of the Affordable Care Act, states have the option to request, subject to the approval of the Secretary, a five-year approval or renewal period for certain Medicaid waivers. Specifically, this time period would apply for demonstration and waiver programs through which a State serves individuals who are dually eligible for both Medicare and Medicaid benefits. This would permit, for example, a state to coordinate a 1915(i) HCBS State Plan Amendment with a 1915(b) managed care authority.
(FAQ9794)
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What if there is an account for someone who is already enrolled in Medicaid?- The flat file contains only accounts that have been determined/assessed as eligible for Medicaid or referred for a full ... (more)
- The flat file contains only accounts that have been determined/assessed as eligible for Medicaid or referred for a full determination at the applicant’s request. If an individual applies at the FFM, is potentially eligible for Medicaid based on income, and does not indicate that he or she is currently enrolled in Medicaid, the FFM does not check for other coverage. The state would do a check with its system as they do when an applicant applies directly to the state and take appropriate action if the person is already enrolled.
(FAQ9538)
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What are the seven conditions and standards that are required for purposes of receiving the enhanced funding?- In accordance with the regulations issued in April 2011, Eligibility & Enrollment projects funded with enhanced fund... (more)
- In accordance with the regulations issued in April 2011, Eligibility & Enrollment projects funded with enhanced funding will have to be: (1) modular; (2) advance the Medicaid Information Technology Architecture (MITA) principle; (3) meet specified industry standards; (4) promote sharing, leverage and reuse of Medicaid technologies of systems within and among States; (5) support business results; (6) meet program reporting; and (7) ensure seamless coordination and integration with the Health Insurance Exchange and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services. Please refer to CMS Guidance on Seven Conditions and Standards available in the CALT (see information in Question 1 about how to access the CALT) and also on www.medicaid.gov at http://www.medicaid.gov/AffordableCareAct/Provisions/Information-Technology-Systems-and-Data.html
(FAQ9386)
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Can a residential agreement between the individual and the entity that owns or controls the property have t...- Yes, however the state must ensure that a lease, residency agreement or other form of written agreement will be in place... (more)
- Yes, however the state must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS participant, and the document provides enforceable protections that address eviction processes and appeals comparable to those provided under the jurisdiction’ s landlord tenant law.
(FAQ12460)
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What methods can states use to execute conversion to modified adjusted gross income (MAGI) as required by t...- Effective January 1, 2014, MAGI eligibility rules will be used to determine eligibility for
nonelderly,... (more)
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 of the 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. The December 28, 2012 guidance is available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO12003.pdf
(FAQ9474)
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What is a standard health plan for purposes of BHP? What benefits are included?- A standard health plan is a health benefits plan in which an individual is enrolled through the BHP. States ... (more)
- A standard health plan is a health benefits plan in which an individual is enrolled through the BHP. States have flexibility in determining the benefits provided under a standard health plan; however, the standard health plan must, at a minimum, provide the essential health benefits. Standard health plans may provide other benefits in addition to the essential health benefits.
(FAQ9978)
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How can states use premium assistance to help families that are split among the Exchange, Medicaid, and the...- In 2014, some low-income children will be covered by Medicaid or CHIP while their parents obtain coverage on the Ex... (more)
In 2014, some low-income children will be covered by Medicaid or CHIP while their parents obtain coverage on the Exchange with advance payments of the premium tax credit. Premium assistance, an option under current law, provides an opportunity for state Medicaid and CHIP programs to offer coverage to such families through the same coverage source, even if supported by different payers. Under Medicaid and CHIP statutory options, states can use federal and state Medicaid and CHIP funds to deliver Medicaid and CHIP coverage through the purchase of private health insurance. Most commonly, states have used premium assistance to help Medicaid/CHIP eligible families pay for available employer-based coverage that the state determines is cost effective. There are cost sharing assistance and benefit wrap-around coverage requirements, to the extent that the insurance purchased with Medicaid and/or CHIP funds does not meet Medicaid or CHIP standards. In both Medicaid and CHIP, premium assistance is authorized for group health coverage and, under some authorities, for health plans in the individual market, which, in 2014 would include qualified health plans available through the Exchange. Please note that advance payments of the premium tax credit and cost-sharing reductions are not available for an individual who is eligible for Medicaid or CHIP. The statutory authorities that permit use of title XIX or title XXI funds to be used for premium assistance for health plans in the individual market, including qualified health plans in the Exchange, are sections 1905(a) and 2105(c)(3) of the Social Security Act.
For example, beginning in 2014, when a child is eligible for Medicaid/CHIP and the parent is enrolled in a qualified health plan through the Exchange, a state Medicaid or CHIP program could use existing premium assistance authority to purchase coverage for a Medicaid or CHIP-eligible child through that qualified health plan. The premium tax credit would not be available to help cover the cost of coverage for these children. As noted above, with respect to the children, the state would adhere to federal standards for premium assistance, including providing wrap-around benefits, cost sharing assistance, and demonstrating cost- effectiveness, as appropriate. A State-Based Exchange may be able to support such an option, and in states where a Federally-Facilitated Exchange is operating, a State Medicaid or CHIP agency may be able to take this approach by making arrangements with qualified health plans to pay premiums for individuals. We will be working with states interested in this option to consider how the state Medicaid and CHIP agency can coordinate with the Exchange to establish and simplify premium assistance arrangements.
(FAQ9496)
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Is there a potential conflict with the Medicaid requirement to process an application within 45 days and th...- The requirements are different, but they are not in conflict. The 45-day limit for Medicaid is the outer boundary ... (more)
- The requirements are different, but they are not in conflict. The 45-day limit for Medicaid is the outer boundary limit by which a State must determine Medicaid eligibility for all individuals who apply on a basis other than disability, and as discussed above, we expect much quicker determinations in most cases. The Medicaid program provides a reasonable opportunity period for individuals whose citizenship or immigration status cannot be verified. Medicaid provides benefits for individuals during their reasonable opportunity period, who are otherwise eligible for Medicaid. The Exchange rule provides for a 90-day reasonable opportunity period for all factors of eligibility. The Exchange determines eligibility without delay and then provides a 90-day reasonable opportunity period for the applicant to provide any additional required information.
(FAQ9366)
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Does a Medicaid application have to be to approved and processed in order for a PE eligibility determinatio...- The purpose of hospital PE and PE more broadly is to provide a streamlined option for people who appear to be eligibl... (more)
The purpose of hospital PE and PE more broadly is to provide a streamlined option for people who appear to be eligible to get access to immediate coverage. The statute makes it clear that a full eligibility determination is not immediately needed and cannot be required in order for hospital PE to be approved.
While states may not require an individual to fill out a full Medicaid application in order to receive a hospital PE determination or before a PE period begins, individuals should be informed that filing a full Medicaid application is necessary for coverage to continue, and states may require that qualified entities assist individuals determined presumptively eligible in completing a full Medicaid application during the PE period.
A state may use the full application for enrollment into hospital PE as long as the application clearly notes which questions need not be answered for PE purposes. An applicant can decide whether to answer those questions at the same time they are enrolling in PE, or to finish the application at a later time. Alternatively, a state could use a separate, short-form hospital PE application and then direct the qualified entity to help the applicant complete the full application by the end of the hospital PE period.
(FAQ9620)
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If an application contains a household which is a mixed case with MAGI and non-MAGI individuals, how should...- Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid und... (more)
- Because the Federally Facilitated Marketplace (FFM) is providing eligibility determinations/assessments for Medicaid under the MAGI standard, the state can process enrollment for MAGI individuals under the waiver authority. Since the FFM is providing non-MAGI applicant referrals on the expanded flat file, the state would act upon the non-MAGI referrals in the same manner as it would through the account transfer service.
(FAQ9532)
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What is the purpose of the final home and community-based services rule (CMS 2249-F and CMS 2296-F)?- The final rule supports enhancement of the quality of home and community-based services (HCBS), adds protections for ind... (more)
- The final rule supports enhancement of the quality of home and community-based services (HCBS), adds protections for individuals receiving services, and provides additional flexibility to states that participate in the various Medicaid programs authorized under section 1915 of the Social Security Act (the Act). Highlights of the final home and community-based services rule include:
• Provides implementing regulations for section 1915(i) State Plan HCBS, including new flexibilities enacted under the Affordable Care Act to offer expanded HCBS and to target services to specific populations;
• Defines and describes the requirements for home and community-based settings appropriate for the provision of HCBS under the Section 1915(c) HCBS waiver, 1915(i) State Plan HCBS and 1915(k) (Community First Choice) authorities;
• Defines person-centered planning requirements across the 1915(c) and 1915(i) authorities;
• Provides states with the option to combine coverage for multiple target populations into one waiver under Section 1915(c), to facilitate streamlined administration of 1915(c) HCBS waivers and to facilitate use of waiver design that focuses on functional needs.
• Allows states to use a five-year renewal cycle to align concurrent waivers and state plan amendments that serve individuals eligible for both Medicaid and Medicare (dual eligibles), such as 1915(b) and 1915(c).
• Provides CMS with additional compliance options beyond waiver termination for 1915(c) HCBS waiver programs.
• Provides an additional exception to the general requirement that payment for services under a state plan must be made directly to the individual practitioner when the state is the primary source of employment for a class of individual practitioners.
(FAQ9784)
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