Payment authority and required documentation for FFS, waivers, demonstrations, and managed care

If services are delivered via fee-for-service, the state must have approved Attachment 4.19‑B pages that comprehensively describe the rate‑setting methodology consistent with section 1902(a)(30)(A); documentation supporting FFP claims for payments to providers must be maintained. For services authorized through a 1915(c) waiver or 1115 demonstration, the rate‑setting methodology and cost estimates must be included in the CMS‑approved waiver or demonstration documentation, and actuarially sound capitation rates are required for managed care.

• FFS: Approved Attachment 4.19‑B pages describing comprehensive rate‑setting methodology consistent with 1902(a)(30)(A) (must support sufficiency to enlist providers and meet efficiency, economy, quality standards).
• 1915(c): Include rate methodology and cost estimates in CMS‑approved waiver application; 1902(a)(30)(A) requirements apply.
• 1115: Budget neutrality required and 1902(a)(30)(A) requirements apply.
• Managed care: Services must be specified in managed care plan contracts and included in actuarially sound capitation rates; states must comply with 42 C.F.R. §§ 438.4–438.7.
• States must have documentation to support any claims for FFP of payments to providers for qualifying section 1947 services delivered to Medicaid beneficiaries.

FFP claiming and reporting — CMS‑37, CMS‑64, and MBES/CBES

To obtain the temporary increased FMAP, states must submit quarterly budget estimates on Form CMS‑37 and reconciliations of actual expenditures on Form CMS‑64; CMS will modify MBES/CBES to support accurate reporting and states must use MBES/CBES (and MACFin for CMS‑37) once available. States must document expenditures to preserve an auditable trail and apply the applicable FMAP based on date of payment.

• Obtain increased FMAP via CMS‑37 budget estimates (Quarterly Distribution of Funding Requirements).
• Reconcile advance FFP via CMS‑64 submissions (Quarterly Medicaid Statement of Expenditures).
• CMS will modify MBES/CBES to allow entry of expenditures at the temporary increased FMAP; prior period adjustments may be used if MBES/CBES delays reporting.
• Applicable FMAP is based on date of payment; recoveries/overpayments must be reported and returned at the same match rate originally claimed.
• States must document expenditures to ensure a clear audit trail isolating expenditures matched at increased FMAP rates.

Include services in managed care contracts and submit SPAs (coverage and 4.19‑B payment pages) for increased FMAP

States must include section 1947 qualifying community‑based mobile crisis intervention services in managed care contracts to claim the increased FMAP for managed care expenditures, and states wishing to add coverage or payment authority must submit SPAs — a coverage SPA for benefits and a separate payment SPA with Attachment 4.19‑B pages for FFS rate methodology — following SPA public notice and tribal consultation requirements.

• Include qualifying services in managed care contracts and identify the portion of capitation rates attributable to these services (using data or reasonable proxy methodologies) to claim the increased FMAP for managed care expenditures.
• To add or modify coverage: submit a coverage SPA under the appropriate benefit category; comply with 42 C.F.R. § 430.20 SPA effective date rules and conduct tribal consultation if required.
• To establish FFS payment rates: submit a separate payment SPA (Attachment 4.19‑B pages) with a comprehensive written rate‑setting methodology consistent with 42 C.F.R. § 430.10 and conduct public notice per 42 C.F.R. § 447.205 (methodology effective no earlier than one day after public notice and the first day of the quarter of SPA submission).
• States must assure adequate non‑federal funding for the state share and have documentation to support any FFP claims for payments to providers of section 1947 services.