Fillable Fmap Claiming Spa Template (Centers for Medicare & Medicaid Services)

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Fmap Claiming Spa Template (Centers for Medicare & Medicaid Services)

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Supplement 18 to Attachment 2.6A
Page 1
1
State Plan Under Title XIX of the Social Security Act
State: _____________
_
ME
THODOLOGY FOR IDENTIFICATION OF APPLICABLE FMAP RATES
The State will determine the appropriate FMAP rate for expenditures for individuals enrolled in the adult
group described in 42 CFR 435.119 and receiving benefits in accordance with 42 CFR Part 440 Subpart C.
The adult group FMAP methodology consists of two parts: an individual-based determination related to
enrolled individuals, and as applicable, appropriate population-based adjustments.
Part 1 – Adult Group
Individual Income-Based Determinations
For individuals eligible in the adult group, the state will make an individual income-based determination for
purposes of the adult group FMAP methodology by comparing individual income to the relevant converted
income eligibility standards in effect on December 1, 2009, and included in the MAGI Conversion Plan (Part
2) approved by CMS on . In general, and subject to any adjustments described
in t
his SPA, under the adult group FMAP methodology, the expenditures of individuals with incomes below
the relevant converted income standards for the applicable subgroup are considered as those for which the
newly eligible FMAP is not available. The relevant MAGI-converted standards for each population group in
the new adult group are described in Table 1.
_______________________
TN –______
____ ______
_______
_ Appro
val Date –___ Eff
ective Date –___
Supplement 18 to Attachment 2.6A
Page 2
2
Table 1: Adult Group Eligibility Standards and FMAP Methodology Features
Covered Populations Within New Adult Group Applicable Population Adjustment
Population Group
Relevant Population Group Income Standard
For each population group, indicate the lower of:
• The reference in the MAGI Conversion Plan (Part
2) to the relevant income standard and the
appropriate cross-reference, or
• 133% FPL.
If a population group was not covered as of 12/1/09,
enter “Not covered”.
Resource
Proxy
Enrollment
Cap
Special
Circumstances
Other
Adjustments
Enter “Y” (Yes), “N” (No), or “NA” in the appropriate column to indicate if
the population adjustment will apply to each population group. Provide
additional information in corresponding attachments.
A B C D E F
Parents/Caretaker
Relatives
Disabled P
ersons, non-
institutionalized
Disabled P
ersons,
institutionalized
Children Ag
e 19 or 20
Childless Ad
ults
TN –__________ Approval Date –__________ Effective Date –__________
Supplement 18 to Attachment 2.6A
Page 3
3
Part 2 – Population-based Adjustments to the Newly Eligible Population
Based on Resource Test, Enrollment Cap or Special Circumstances
A. Optional Resource Criteria Proxy Adjustment (42 CFR 433.206(d))
1. The s
tate:
☐ Applies a resource proxy adjustment to a population group(s) that was subject to a resource test
that was applicable on December 1, 2009.
☐ Does NOT apply a resource proxy adjustment (Skip items 2 through 3 and go to Section B).
Table 1 indicates the group or groups for which the state applies a resource proxy adjustment to the
expenditures applicable for individuals eligible and enrolled under 42 CFR 435.119. A resource
proxy adjustment is only permitted for a population group(s) that was subject to a resource test that
was applicable on December 1, 2009.
The effective date(s) for application of the resource proxy adjustment is specified and described in
Attachment B.
2. Data source used for resource proxy adjustments:
The state:
☐
☐
☐
☐
__________
Applies existing state data from periods before January 1, 2014.
Applies data obtained through a post-eligibility statistically valid sample of individuals.
Data used in resource proxy adjustments is described in Attachment B.
3. Resource Proxy Methodology: Attachment B describes the sampling approach or other
methodology used for calculating the adjustment.
B. Enrollment Cap Adjustment (42 CFR 433.206(e))
1. An enrollment cap adjustment is applied by the state (complete items 2 through 4).
An enrollment cap adjustment is not applied by the state (skip items 2 through 4 and go to
Section C).
TN –__________ Approval Date – Effective Date –__________
Supplement 18 to Attachment 2.6A
Page 4
2. Attachment C describes any enrollment caps authorized in section 1115 demonstrations as of
December 1, 2009 that are applicable to populations that the state covers in the eligibility group
described at 42 CFR 435.119 and received full benefits, benchmark benefits, or benchmark
equivalent benefits as determined by CMS. The enrollment cap or caps are as specified in the
applicable section 1115 demonstration special terms and conditions as confirmed by CMS, or in
alternative authorized cap or caps as confirmed by CMS. Attach CMS correspondence confirming
the applicable enrollment cap(s).
4
☐
☐
__________ __________
☐
3. Th
e state applies a combined enrollment cap adjustment for purposes of claiming FMAP in the adult
group:
Yes. The combined enrollment cap adjustment is described in Attachment C
☐
No.
4. Enrollment Cap Methodology: Attachment C describes the methodology for calculating the
enrollment cap adjustment, including the use of combined enrollment caps, if applicable.
C. Special Circumstances (42 CFR 433.206(g)) and Other Adjustments to the Adult Group FMAP
Methodology
1. The state:
☐
☐
Applies a special circumstances adjustment(s).
Does not
apply a special circumstances adjustment.
2. Th
e state:
Applies additional adjustment(s) to the adult group FMAP methodology (complete item 3).
Does not
apply any additional adjustment(s) to the adult group FMAP methodology (skip item 3
and go to Part 3).
3. Attachment D describes the special circumstances and other proxy adjustment(s) that are applied,
including the population groups to which the adjustments apply and the methodology for
calculating the adjustments.
TN – Approval Date –_
_________ Effective Date –
Supplement 18 to Attachment 2.6A
Page 5
5
Part 3 – One-Time Transitions of Previously Covered Populations into the New
Adult Group
A. Transitioning Previous Section 1115 and State Plan Populations to the New Adult Group
☐ Individuals previously eligible for Medicaid coverage through a section 1115 demonstration
program or a mandatory or optional state plan eligibility category will be transitioned to the
new adult group described in 42 CFR 435.119 in accordance with a CMS-approved transition
plan and/or a section 1902(e)(14)(A) waiver. For purposes of claiming federal funding at the
appropriate FMAP for the populations transitioned to new adult group, the adult group FMAP
methodology is applied pursuant to and as described in Attachment E, and where applicable, is
subject to any special circumstances or other adjustments described in Attachment D.
☐ The state does not have any relevant populations requiring such transitions.
Part 4 - Applicability of Special FMAP Rates
A. Expansion State Designation
The state:
☐
☐
Does NOT meet the definition of expansion state in 42 CFR 433.204(b). (Skip section B and go to
Part 5)
Meets the definition of expansion state as defined in 42 CFR 433.204(b), determined in
accordance with the CMS letter confirming expansion state status, dated _________________.
☐
B. Qualification for Temporary 2.2 Percentage Point Increase in FMAP.
The state:
☐
Does NOT qualify for temporary 2.2 percentage point increase in FMAP under 42 CFR
433.10(c)(7).
Qualifies for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7),
determined in accordance with the CMS letter confirming eligibility for the temporary FMAP
increase, dated _____________
. The state will not claim any federal funding for individuals
determined eligible under 42 CFR 435.119 at the FMAP rate described in 42 CFR 433.10(c)(6).
TN –
__________ Approval Date –
__________ Effective Date –__________
Supplement 18 to Attachment 2.6A
Page 6
6
☐
☐
☐
☐
☐
Part 5 - State Attestations
The State attests to the following:
A. The application of the adult group FMAP methodology will not affect the timing or approval of any
individual’s eligibility for Medicaid.
B. The application of the adult group FMAP methodology will not be biased in such a manner as to
inappropriately establish the numbers of, or medical assistance expenditures for, individuals
determined to be newly or not newly eligible.
ATTACHMENTS
Not all of the attachments indicated below will apply to all states; some attachments may describe
methodologies for multiple population groups within the new adult group. Indicate those of the following
attachments which are included with this SPA:
Attachment A – Conversion Plan Standards Referenced in Table 1
Attachment B – Resource Criteria Proxy Methodology
Attachment C – Enrollment Cap Methodology
Attachment D – Special Circumstances Adjustment and Other Adjustments to the Adult Group FMAP
Methodology
Attachment E – Transition Methodologies
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information
collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
TN –_
_________
Approval Date –__________ _______
Effective Date –___
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Fmap Claiming Spa Template (Centers for Medicare & Medicaid Services)

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Completed 24 July 2020

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