Frequently Asked Questions

Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.

FAQ ID:92416

Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.

FAQ ID:92421

The UPL data for out of state providers does not need to be included in the UPL demonstration. If the state has provider level data then it may include it in the demonstration within the private ownership category of providers.

FAQ ID:92426

CMS understands that many managed care contracts include a general provision that incorporates changes in federal law during the course of the contract term. Amendments to approved contracts, or contracts under CMS review, for the purpose of updating regulatory citations is not necessary. However, the citations will need to be updated for the next contract year. Outdated regulatory citations in contracts without such a general provision will need to be updated for the next contract year.

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FAQ ID:93426

No. If a state does not have a state law or policy that requires CMS approval of the contract and capitation rates prior to the effective date of the contract, the 90 day timeframe is not applicable. However, as a general matter, states should submit the contracts and rates 90 days prior to the start of the contract term. CMS intends to provide future guidance on the prior approval requirements as a condition of claiming FFP in section 438.806, which are distinct from the requirements at section 438.3(a).

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• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93431

There is a technical error in section 438.210(a)(2) as the cross-reference should have incorporated subpart B of part 441 rather than subpart B of part 440. All Medicaid beneficiaries under age 21 are entitled to EPSDT services, whether they are enrolled in a managed care plan or they are in fee-for-service. Under section 1905(r) of the Social Security Act (the Act), EPSDT services must include ""[s]uch other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and physical and mental illness and conditions discovered by the screening services, whether or not such services are covered under the State plan."" CMS intends to issue a regulatory correction to address this error. We also want to remind readers that sections 1902(a)(43) and 1905(r)(5) of the Act are applicable to the provision of EPSDT, despite not being expressly incorporated in part 441. Detailed guidance on EPSDT can be found in ""EPSDT"" A Guide for States: Coverage in the Medicaid benefit for Children and Adolescents, June 2014, available at https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf (PDF, 613.1 KB).

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• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93436

No. CMS addressed this provision at page 27569 of the Final Rule. Section 438.4(b)(5) does not require there to be different assumptions (such as trend or age, gender, or regional rating) for each rate cell and does not prevent the use of the same assumptions across more than one rate cell. The prohibition on cross-subsidization among rate cells under the contact is to ensure prudent fiscal management and that the capitation rate for each rate cell is independently actuarially sound.

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FAQ ID:93441

No. For the rating periods for contracts starting on or after July 1, 2017, managed care plans may not maintain more than one level of appeal. Section 438.402(b) requires that MCOs, PIHPs, and PAHPs ""may have only one level of appeal for enrollees."" Note that states may modify managed care contracts to require managed care plans to provide one level of internal appeal in advance of the rating period for contracts starting on or after July 1, 2017, as subpart F in the 2002 final rule permitted states flexibility as to the number of internal appeals. Please see page 27509 of the Final Rule for additional explanatory information.

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FAQ ID:93446

No, not for the rating period for contracts starting on or after July 1, 2017. Section 438.402(c)(1)(i) requires that the enrollee exhaust the internal level of appeal before requesting a State fair hearing. Note that if the MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in section 438.408, section 438.402(c)(1)(i)(A) provides that the enrollee is deemed to have exhausted the internal level of appeal and may request a State fair hearing. States may modify managed care contracts to require exhaustion of the internal level of appeal in advance of the rating period for contracts starting on or after July 1, 2017, as subpart F in the 2002 final rule permitted states flexibility to determine whether exhaustion would be required. Please see page 27509 of the Final Rule for additional explanatory information.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93451

Yes. CMS acknowledges that states may have legitimate reasons to set capitation rates for a time period that differs from 12 months and will take unusual circumstances into account when reviewing compliance with the rating period duration requirements. CMS will approve a rating period other than of 12 months when a state transitions the contract term and rating period from a calendar year to a state fiscal year basis and setting capitation rates for a 6 month or 18 month period would facilitate that transition. There may be other reasonable justifications for such variations in the rating period that CMS would be open to considering. The rationale for a rating period that differs from 12 months as defined in the regulation in section 438.2 should be specified in the rate certification required in section 438.7 for such consideration.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93456