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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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Our state included dental services along with physician (non-dental) services in our state's Upper Payment Limit (UPL) demonstration of the practitioner Average Commercial Rate (ACR) using the Medicare Equivalent of the ACR. Should we keep both services together in one demonstration or should we separate the services out for two different ACR demonstrations?

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.

FAQ ID:92441

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Our Inpatient Hospital Upper Payment Limit (UPL) demonstration is too large to send in one workbook, can we submit our demonstration to CMS in multiple workbooks? Alternatively, may states submit separate workbooks for each ownership category?

Yes, a state should submit multiple workbooks to CMS to provide a complete UPL demonstration for each service category subject to the UPL (Inpatient Hospital services (IPH), Outpatient Hospital services (OPH), Nursing Facility services (NF), Clinic, Institutions for Mental Disease (IMD), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Psychiatric Residential Treatment Facility (PRTF), and Qualified Practitioner supplemental payments). When submitting UPL demonstrations, the state should 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.As well, states may submit one separate workbook for each ownership category (state government owned, non-state government owned, and private).

FAQ ID:92241

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Now that Upper Payment Limit (UPL) demonstrations are submitted to a central e-mailbox, will the CMS Regional Office still have a role in reviewing UPL demonstrations or will the review be performed by the Central Office?

The Regional Office will continue to review state UPL demonstrations and states will continue to work with the CMS Regional Offices as a first point of contact concerning their UPL demonstrations.

FAQ ID:92256

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