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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

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Can a state type information and data into unlocked fields in the Upper Payment Limit (UPL) templates or must the data from state-developed UPL reports/workbooks be mapped through, for example, V-Look-ups into the UPL templates?

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.

FAQ ID:92451

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Does CMS require states to submit their 2019 Upper Payment Limit (UPL) demonstrations using the Office of Management and Budget (OMB) approved templates for Inpatient Hospital services (IPH), Outpatient Hospital services (OPH), and Nursing Facility services (NF) UPLs?

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

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If a state's inpatient hospital, outpatient hospital, or nursing facility Upper Payment Limit (UPL) demonstration has been approved by CMS for demonstration year 2018, does the UPL template still need to be populated and submitted for 2018?

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

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Are there any circumstances that would allow a state to apply the same Upper Payment Limit (UPL) demonstration to multiple years?

When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.

FAQ ID:92221

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