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

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

No one loses coverage as a result of converting to MAGI rules, but, in states that don't adopt the new adult eligibility group, it is possible that some individuals will lose coverage.

The Affordable Care Act ensured that no one would lose health coverage--if they were not eligible under the new MAGI standards either they would be covered under the new Medicaid adult coverage group or they would be able to purchase insurance through the Marketplace with the benefit of a premium tax credit and likely cost sharing reductions. Following the Supreme Court's decision, the Medicaid expansion is voluntary for states, and in states that do not adopt the new coverage group some individuals may lose coverage at the time of their renewal when the new rules are applied.

FAQ ID:92501

No, the change to MAGI does not affect the size of CHIP Programs.

The number of children in CHIP does not change as a result of MAGI because the new standards have the same value as the old standards; they simply translate the state's pre-MAGI two-step policies into a simpler one-step calculation. For example, if the state under old rules covers children in Medicaid with incomes up to 150% of the Federal Poverty Limit (FPL) and CHIP from 150% to 200% of the FPL, and under MAGI the new Medicaid income standard is 160% of the FPL, that doesn't mean that children between 150% and 160% are losing CHIP coverage--it means that many children between 150% and 160% of the FPL using net income standards were already eligible for Medicaid because of the use of disregards.

FAQ ID:92506

No, the number of children moving from CHIP to Medicaid is not affected by the change to MAGI.

Under the law, those states that cover children ages 6-18 with incomes between 100% and 133% of the FPL in CHIP will be transitioning these children to Medicaid so that children under 133% of the FPL, regardless of their age, are eligible for the same coverage program (some states will continue to have different, higher income standards for younger children). The change to MAGI standards does not change the number of children who will move from CHIP to Medicaid.

FAQ ID:92511

Yes. The new converted standards are based on the state's current income eligibility standards and their pre-2014 disregards. So if children in different age groups have different effective eligibility levels under a state's pre-2014 rules, the children will have different converted standards. For example, if a state has been covering children aged 1-5 to 133% FPL and children aged 6-18 to 100% FPL, the state's MAGI eligibility standard in 2014 may be 139% FPL for children aged 1-5 and 133% FPL for older children.

FAQ ID:92516

Yes, states can adjust their standards within certain limits established by law.

States can adjust both their adult standards (e.g., for pregnant women) and their children standards, as long as they do not reduce eligibility levels below minimum standards established by the law. CMS can advise states of their options.

FAQ ID:92521