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Page 22 – FAQs

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. For individuals who would otherwise transition to the adult group after the 60-day postpartum period, the state would typically determine whether they meet the requirements for coverage under the adult group and the newly eligible criteria under 42 C.F.R. § 433.204(a)(1) for the purpose of the increased FMAP. However, because a state adopting the option to provide 12 months of postpartum coverage does not need to conduct a redetermination of eligibility until the end of the extended postpartum period, the state might not conduct the determination under Subpart E of Part 433 for adult group FMAP. Instead, states seeking to claim the increased FMAP for newly eligible individuals enrolled in the adult group may adopt a proxy methodology to determine the percentage of beneficiaries who would have transitioned to alternative benefit package coverage as newly eligible beneficiaries in the adult group for whom newly eligible FMAP is available. Once the methodology is approved by CMS, the state would apply the relevant percentage to medical assistance expenditures for the entire extended postpartum population to claim the increased FMAP for the proportion of newly eligible individuals determined under the proxy methodology.

If a state chooses to conduct renewals based on available information as discussed in Q19 and Q20, this will have implications on whether and how a state develops a proxy methodology to claim newly eligible FMAP. CMS will provide additional technical assistance on the possibility of using a proxy methodology to states in this circumstance. SPAs and Capitation Rate Amendments

Q23. Are states required to submit separate state plan amendments (SPA) to provide extended postpartum coverage in Medicaid and its separate CHIP?

A23. Yes. States must submit a Medicaid SPA as well as a CHIP SPA in order to make the election in both programs. CMS will make a Medicaid SPA template available in MACPro and a CHIP SPA template available in MMDL.

Q24. Are states required to create new managed care capitation rates for a 12-month postpartum period?

A24. Capitation rates paid by states to Medicaid managed care plans must be actuarially sound in accordance with 42 C.F.R. § 438.4, including that the capitation rates are appropriate for the populations to be covered and the services to be furnished under the contract between the state and plan. Therefore, the state’s actuary must evaluate if programmatic changes to the managed care program, such as a change in eligibility and coverage, impact the development of actuarially sound capitation rates or require a rate amendment if the programmatic change occurs after the development of the capitation rates for the applicable rating period. The state and its actuary should ensure that the rate development standards and documentation expectations outlined in the Medicaid Managed Care Rate Development Guide are met within the rate certification.