Frequently Asked Questions

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

To date, CMS has not published a list of revenue codes that must be included or excluded from this service category.  Medicaid outpatient hospital services are defined at 42 Code of Federal Regulations (CFR) 440.20 and include “preventive, diagnostic, therapeutic, rehabilitative, or palliative services”.  In the state plan, states further define those services covered as outpatient hospital services.

FAQ ID:92411

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

States are required to cover certain benefits and others are optional. To learn what your state covers, contact your state Medicaid agency. To learn more about the Federal rules around mandatory and optional services, visit the benefits page.

FAQ ID:95101

Contact your state Medicaid agency. They can help answer your coverage questions and what to do when you have an access problem due to the declared emergency.

FAQ ID:95046

Contact your state Medicaid agency. They can help you get replacement cards and answer your questions about what services are covered, providers to use, and how to renew your eligibility.

FAQ ID:94571

Your state will determine if you qualify for Medicaid. Contact your state for renewal or application information.

FAQ ID:93381

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Since Medicaid is administered by the Medicaid agency in your state, eligibility may vary from one state to another. Contact your state Medicaid Agency with questions, or see if you qualify by applying. CMS is the federal agency that works with state Medicaid agencies to make sure they comply with federal laws and regulations.

FAQ ID:94506