Frequently Asked Questions

No, an upper payment limit demonstration considers all Medicaid payments (base and supplemental). States must conduct UPL demonstrations for the applicable services described in State Medicaid Director Letter (SMDL) 13-003 regardless of whether a state makes supplemental payments under the Medicaid state plan for the services.

FAQ ID:92191

Yes, the templates allow the use of multiple cost centers. For example, if the state uses a cost methodology for ancillary services and a per-diem methodology for routine services, the state will complete one cost template and one per-diem template in order to account for these two cost centers. Every hospital would be featured in each of the two templates; however, to differentiate their provider information, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the cost template as 123456-A and in the per diem template as 123456-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number. If there are multiple cost centers under either the cost or per-diem methodology, the state would separate out the cost centers within their respective templates. Each cost center should be associated with only one appended letter and these should be described in the notes tab. When using multiple cost centers, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.

FAQ ID:92261

Yes, the template allows the use of multiple cost centers with multiple cost-to-charge ratios. The state would separately report the costs and payments associated with each of the cost centers in the cost template. To differentiate the cost centers, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, for example an -A, -B, or -C, that would be used as a unique identifier for each cost center.

FAQ ID:92266

Yes, the templates allow the use of multiple methodologies. The state would complete the templates associated with the UPL methodologies used. For example, if the state uses a cost-based methodology for state owned hospitals and a payment-based methodology for private hospitals, then the state would complete the cost template for the state owned hospitals and the payment template for the private hospitals. When using multiple methodologies, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.

FAQ ID:92271

Variable 408 (Adjustment to the UPL Gap) is intended to allow states to report adjustments to their UPL gap, to the extent that these adjustments are not accounted for in other variables. Here, states could report broad-based increases or reductions in payment, such as a Medicaid volume adjustment for managed care expansion. The source of values input into variable 408 may differ by state. Whenever a state reports data in variable 408 it must include a comprehensive note describing the adjustment.

FAQ ID:92301

The cost of the tax should be reported in Variable 401 - MCD Provider Tax Cost. A state may separately report the Medicaid portion of the cost of a provider assessment/tax only when it is using a cost based methodology to calculate the UPL. A state may not include this cost when calculating a DRG or Payment based UPL demonstration.

FAQ ID:92366

Yes, a state may choose between using all-payer data or Medicare-specific data from the Medicare Hospital Cost Report (CMS Form 2552) to determine the cost-to-charge ratios.

FAQ ID:92406

Within the parameters set by State Medicaid Director (SMD) Letter #11-004 and SMD Letter #10-016, states may request 90/10 HITECH administrative funding for a wide range of HIE activities that support meaningful use.

States may request this funding for two broad categories of their administrative activities related to HIEs: (1) on-boarding, and (2) design, development, and implementation (DDI) of infrastructure. In this context, on-boarding refers to the state's or HIE's activities related to connecting a provider to an HIE so that the provider is able to successfully exchange data and use the HIE's services; this funding cannot cover costs incurred by the provider or the vendor. For more information, please see the later FAQ that specifically discusses on-boarding. With respect to infrastructure DDI, CMS is able to provide matching funds for a variety of state activities that will enable providers who are eligible for the Medicaid EHR Incentive Program to meet meaningful use. If the requirements of SMD Letters #10-016 and #11-004 are met, CMS will provide funding for state administrative activities related to core HIE services (for example, designing and developing a provider directory, privacy and security applications, and/or data warehouses), public health infrastructure, and electronic Clinical Quality Measurement (eCQM) infrastructure.

CMS recognizes that there are multiple types of HIE models emerging among the states, and will review each proposal individually. SMD Letter #11-004 outlines some of the characteristics that CMS encourages, but a state may provide justification for why an alternate model is more appropriate given the unique circumstances in that state. CMS encourages interested states to reach out to their CMS regional HITECH contacts to discuss any proposed HIE funding requests prior to submitting an Implementation Advance Planning Document Update (IAPD-U) for HIE funding. Please note that cost allocation and fair share principles are critical requirements outlined in SMD Letter #11-004, and so the state must ensure that its funding request complies with the principles outlined in the SMD letter.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 288.05 KB)

FAQ ID:92526

Yes, but only in specific circumstances. States may request time-limited HITECH funding for staffing costs related to on-boarding eligible Medicaid providers to the HIE or to building initial infrastructure. The staff may sit in the state Medicaid agency or the HIE itself, depending on the state's situation. Any staffing costs for on-boarding or infrastructure must be time-limited to ensure that the costs do not become operational in nature. When requesting HITECH funds to cover staffing costs, states should present a justification that describes how many eligible providers are anticipated to on-board to the HIE and the amount of staffing time necessary to on-board those providers or build infrastructure.

Please note that HITECH administrative funding will also be available for personnel that sit within the Medicaid agency itself and support only Medicaid providers. However, the fair share and cost allocation principles outlined in the State Medicaid Director (SMD) Letter #11-004 still apply. If those personnel work on other State Medicaid program activities that do not benefit the Medicaid EHR Incentive Program, then HITECH funds must be cost allocated between the Medicaid EHR Incentive Program and the Medicaid agency personnel's other activities.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 288.05 KB)

FAQ ID:92531

State Medicaid Director (SMD) Letter #11-004 and SMD Letter #10-016 indicate that states may request 90/10 HITECH administrative funding for HIE infrastructure under the Medicaid EHR Incentive Program. To request this funding, states must submit an Implementation Advance Planning Document Update (IAPD-U) using the approved template, which can be found at http://www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/Downloads/Medicaid_HIT_IAPD_Template.pdf. In particular, the IAPD-U template Appendix D outlines all the information required for an HIE funding request. The HIE funding request may be submitted in a separate IAPD-U, or it may be included in an IAPD-U that requests other funding for the state's Medicaid EHR Incentive Program.

CMS asks that states reach out early to their regional CMS HITECH contacts if they are considering submitting an IAPD-U for HIE funding. Given the complexity of an HIE request, along with the parameters set out in SMD Letter #11-004, CMS prefers to have one or more preliminary discussions to go over the state's current IAPD landscape, the state's technical model, and the state's approach to meeting the fair share and cost allocation principles.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 288.05 KB)

FAQ ID:92536