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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

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Can you explain the difference between a prospective Upper Payment Limit (UPL) and a retrospective UPL?

The difference between a prospective and retrospective UPL is in the relationship between the UPL demonstration period and the date when the UPL is submitted. For a UPL demonstration period of 7/1/2018 to 6/30/2019, a UPL is considered retrospective when it is submitted on or after the start of the demonstration period (on or after 7/1/2018). Using the same UPL demonstration period (7/1/2018 to 6/30/2019), a UPL is considered prospective if it is submitted prior to 7/1/2018.

FAQ ID:92431

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If we complete multiple inpatient templates for Diagnosis Related Groups (DRG) and per diem, should they be in the same file or separate files? Should there be a summary of all the inpatient Upper Payment Limits (UPLs) showing grand totals?

The state should complete one template each for the DRG and per diem UPL calculations and these should be placed in one file. The state should also include a summary worksheet in the same file that shows the UPL gap for each ownership category (state government owned, non-state government owned, and private). States should include all necessary supporting documentation.

FAQ ID:92276

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