Frequently Asked Questions

The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.

FAQ ID:92231

Yes, states may use UPL methodologies that are different from their payment methodologies. For example, a state may pay for inpatient hospital services using a Medicaid APR-DRG methodology, but use a cost methodology to compute the Medicare upper payment limit for its UPL demonstration.

FAQ ID:92386

The statute and regulations require that states provide individuals several channels through which they can apply for Medicaid and CHIP coverage - by mail, in person, on line and over the telephone. Following are some guiding principles for administering telephonic applications based on successful strategies many states have in place today.

1. Accepting a Telephonic Application - States may develop their own processes for accepting and adjudicating telephonic applications. The process for accepting applications by phone must be designed to gather data into a sufficient format that will be accessible for account transfer to the appropriate insurance affordability program. For example, a customer service representative could verbally communicate application questions to the applicant, while electronically filling out the online version of the single streamlined application.
2. Voice Signatures - All applications must be signed (under penalty of perjury) in order to complete an eligibility determination. In the case of telephonic applications, states must have a process in place to assist individuals in applying by phone and be able to accept telephonically recorded signatures at the time of application submission. If applicable, states can maintain their current practices of audio recording and accepting voice signatures as required for identity proofing.
3. Records and Storage - Upon request, states must be able to provide individuals with a record of their completed application, including all information used to make the eligibility determination. As such, CMS recommends that states record all telephonic applications. This may be accomplished by taping the complete application transaction as an audio file, or by producing a written transcript of the application transaction, among other options. The length of storage of these records should comply with current regulations on application storage.
4. Confirmations and Receipts - States should provide a confirmation receipt documenting the telephonic application to the applicant. Such confirmation should be provided upon submission of the application or at any time the applicant wishes to end the customer representative interaction. Confirmation receipts can be delivered via electronic or paper mail (based on the applicant's preference). Confirmation receipts must include key information for applicants, including but not limited to the application summary, the eligibility determination summary page, a copy of the attestations/rights and responsibilities and the submission date of the signed application.

• This FAQ was released as part of a larger set. View the full set. (PDF, 295.71 KB)

FAQ ID:92156

For technical assistance with the implementation efforts and assistance with determining if current state practices are below the FFP limit, please contact the Medicaid DME mailbox: MedicaidDME@cms.hhs.gov.

FAQ ID:93476

States may review Medicare’s CBAs through the following website for the most up-to-date information: www.dmecompetitivebid.com. In the alternative, the Center for Medicaid and CHIP Services (CMCS) has a list of states and CBAs by state that is available upon request. We will monitor the lists and update them with any necessary Medicare changes. As of January 1, 2018, the following states and territories do not have CBAs: Alaska, Maine, Vermont, North Dakota, South Dakota, Montana, Wyoming, and all of the US territories.

FAQ ID:93481

Federal financial participation (FFP) limit demonstrations for durable medical equipment (DME) will be due 3 months after the end of the calendar year for the previous calendar year (i.e., January 1-December 31). The first DME FFP limit demonstration will be due by March 31, 2019 and will contain data for the period of January 1, 2018 to December 31, 2018. This reporting period was selected to coincide with the effective date of the statute (January 1, 2018).

FAQ ID:93486

The statute does not compel states to set their payment rates for durable medical equipment (DME) at specific Medicare rates for each specific item. Instead, the statute applies a limit on available federal financial participation (FFP) for state aggregate expenditures. States have the flexibility to set their own rates for DME in the Medicaid program. If a state decides to set their Medicaid payment rates at or below Medicare rates in the state plan, the state should be specific about the fee schedule the state will use and be prepared to demonstrate that their rates do not exceed the amount Medicare would have paid in the aggregate, in order to avoid the annual FFP limit demonstration of aggregate expenditures. For the demonstration, the Centers for Medicare & Medicaid Services (CMS) will be using state-specific Medicare payment rates. With this limit of available FFP for the aggregate amount of DME, CMS will use either the Medicare rates specific to an area of the state for the services rendered in those areas, or the lowest of a state’s Medicare rates for comparison to the aggregate limit of FFP.

FAQ ID:93491

States are free to establish higher rates for particular items of DME if they determine that higher rates are needed under the Medicaid state plans. If, however, the aggregate expenditures would exceed the Medicare rates in the aggregate, federal financial participation (FFP) would be limited. States that determine that payments above Medicare aggregate totals are necessary may use state-funds to obtain particular items of DME. The statute specifically describes an aggregate limit on state expenditures only for purposes of paying FFP. Therefore, a state may pay more than the Medicare rate for a particular item of DME, and as long as the aggregate amount for all DME is not exceeded, no FFP is at risk. Even if the aggregate amount is exceeded, there is only a limit on FFP, and there is no limit on the use of state funds used on DME items.

FAQ ID:93496

The Centers for Medicare & Medicaid Services cannot delay implementation of the statute. Congress took specific action to move the effective date up to January 1, 2018, and we are unable to amend the effective date.

FAQ ID:93501

The limit on FFP is the total aggregate amount for all relevant DME subject to the limit described in Section 1903(i)(27) of the Act.

FAQ ID:93506