Frequently Asked Questions

In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.

Yes. Mapping data, through V-Look-ups, for example, is a much easier and consistent process for current and future UPL submissions. However, a state may choose to type information and data into unlocked fields in the UPL templates. When a state chooses to input data directly (not through a V-Look-up) into the template, it still must provide the supporting documentation with the source data. Additionally, the state should explain how it mapped data from the supporting documentation into the template. The Centers for Medicare & Medicaid Services utilizes the supporting information to confirm that the information in the templates is correct.

Effective state fiscal year 2020, each state must submit a complete data set of payments to Medicaid providers, including providers paid at cost, as well as critical access hospitals. This would require states to submit cost and payment data to CMS that previously was not requested.

The difference between a prospective and retrospective UPL is in the relationship between the UPL demonstration period and the date when the UPL is submitted. For a UPL demonstration period of 7/1/2018 to 6/30/2019, a UPL is considered retrospective when it is submitted on or after the start of the demonstration period (on or after 7/1/2018). Using the same UPL demonstration period (7/1/2018 to 6/30/2019), a UPL is considered prospective if it is submitted prior to 7/1/2018.

The UPL limits payment to the Medicare rate or cost. Providers paid at reconciled cost may receive no more than their reconciled amount. As a result, states cannot attribute the “UPL room” from other providers to pay additional amounts to any provider paid at reconciled cost. Due to this payment limitation, states should not include any provider paid at reconciled cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at reconciled cost and confirm by provider use of either a Medicare cost report or Centers for Medicare & Medicaid Services-approved cost report template to identify allowed cost. Further, states must document the ownership status (state owned, non-state government owned, or private) of each provider.

Dental services are not covered under Medicare, which means the state may not compare Medicaid rates for comparable dental services for the Medicare Equivalent of the ACR. The state may calculate a dental ACR in order to make supplemental payments to dental services providers and continue to calculate the Medicare Equivalent of the ACR for other services covered by Medicare. The state should submit two separate ACR demonstrations, one for dental services and one for physician (non-dental) services. This will involve completing two versions of the Office of Management and Budget-approved template. If the same provider provides both physician and dental services the state would differentiate the provider information between the two demonstrations by appending 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 physician ACR as 123456-A and in the dental ACR as 12345-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number.

Where inflation is not applied to property costs, please separate out this cost from the Medicare UPL by reporting these amounts in variable 402 - Adjustment to the Medicare UPL.

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.

No, the template does not include variables to report clinical diagnostic laboratory services.

The Notes tab should include any and all information to fully support the state's UPL demonstration. CMS expects states to provide clarifying information in the Notes tab. For example, this information would provide details for the adjustments to Medicare as input in variables 212.1 and 212.2, various supplemental payments in variables 313.1, 313.2, and 313.3, and adjustments to Medicaid in variables 314.1 and 314.2. In addition to reporting through the notes tab, the state also has the option of using the guidance document or narrative to fully support its UPL demonstration.