Frequently Asked Questions

States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.

FAQ ID:92251

The Regional Office will continue to review state UPL demonstrations and states will continue to work with the CMS Regional Offices as a first point of contact concerning their UPL demonstrations.

FAQ ID:92256

Yes, CMS requires states to use all of the OMB approved templates for their 2019 (07/01/2018 to 06/30/2019) UPL demonstrations submitted to meet the annual UPL reporting requirement and with State Plan Amendment (SPA) submissions. When submitting UPL demonstrations, use the following naming convention: UPL_<UPL Demo Date Range>_<Service Type Abbreviation>_R<Region Number>_<State Abbreviation>_<Workbook Number>.xls. Here is an example of the naming convention: UPL_20170701-20180630_IP_R01_CT_01.xls.

FAQ ID:92196

No, if a state's payment methodology describes payment at no more than 100 percent of the Medicare rate for the period covered by the UPL then it does not need to submit a demonstration using the template(s). To show the state has met the annual UPL demonstration reporting requirement it should make CMS aware that it is paying no more than the Medicare rate.

FAQ ID:92201

No, states that already have submitted their 2018 (07/01/2017 - 06/30/2018) inpatient hospital, outpatient hospital, or nursing facility services UPL demonstrations will not have to resubmit using the templates. In that instance, CMS will populate the templates using data already submitted by the state.

FAQ ID:92211

Yes, a demonstration submitted within the fiscal year that is used to document that SPA methodology changes comply with the UPL requirements may be used to satisfy the SMDL requirements as long as no subsequent changes are made to the state's provider payment methodology prior to the state's annual submission and CMS has reviewed and accepted the demonstration.

FAQ ID:92216

It's a new, simpler way to determine eligibility for Medicaid and CHIP.

The Affordable Care Act provides new simplified method for calculating income eligibility for Medicaid, CHIP and financial assistance available through the health insurance Marketplace. This new method calculates eligibility for all programs based on what is called modified adjusted gross income (MAGI). By using one set of income eligibility rules across all insurance affordability programs, the new law makes it easier for people to apply for health coverage through one application and enroll in the appropriate program. MAGI will replace the current process for calculating Medicaid eligibility that is in place today, which uses income deductions (known as "disregards") that are different in each state and often differ by eligibility group.

FAQ ID:92461

The new rules apply to most people who are eligible for Medicaid and Chip, but not the elderly or people who qualify based on a disability.

For coverage effective January 2014, MAGI will be the basis for determining both Medicaid and CHIP eligibility for children, pregnant women, parents and the adults enrolled under the new adult eligibility group created by the ACA (in states that adopt that eligibility group.) Individuals age 65 and older and those who qualify for Medicaid based on disability are not affected by the new rules.

FAQ ID:92466

Yes. A state's decision whether or not to extend Medicaid coverage for low-income adults in 2014 is not related to the use of MAGI. MAGI rules simplify the eligibility rules and promote coordination between Medicaid and CHIP and coverage available through the Marketplace; coordination will be important for consumers in all states regardless of a state's decision on Medicaid eligibility for low-income adults.

FAQ ID:92471

The eligibility standards (where there's been no expansion) are not any higher than the old standards; they are expressed in a different way (gross versus net).

In the past, Medicaid and CHIP eligibility used a combination of an income eligibility standard--often expressed as a percentage of the Federal Poverty Level (FPL)--and a series of deductions (known as "disregards" that were like footnotes or 'below the line' adjustments to income and were determined by each state. The new way of calculating eligibility based on MAGI translates that two-part process into a one step process using an income standard that incorporates the 'below the line' deductions. This makes the new standard appear higher than the old one (e.g. from 185% of the FPL to 193% of the FPL for pregnant women). In effect, however, the new income standard represents what the state's old two-step process would have resulted in, just expressed in a different way.

FAQ ID:92476