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.
Frequently Asked Questions
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.
Can a state use an Upper Payment Limit (UPL) demonstration that was submitted within the fiscal year for purposes of demonstrating that a State Plan Amendment (SPA) change complies with the regulations in order to meet the State Medicaid Director Letter (SMDL) requirements?
Yes, a demonstration submitted within the fiscal year that is used to document that SPA methodology changes comply with the UPL requirements may be used to satisfy the SMDL requirements as long as no subsequent changes are made to the state's provider payment methodology prior to the state's annual submission and CMS has reviewed and accepted the demonstration.
What materials does CMS require a state to submit as part of the Upper Payment Limit (UPL) Demonstration submission package?
The submission package consists of the completed templates and any supporting documentation needed to understand the UPL demonstration. This could include the completed Guidance document and supporting documentation (in Microsoft Excel with formulas included, not as a PDF) that is necessary to further explain a state's UPL demonstration, and a summary spreadsheet that aggregates the UPL gap for each of the ownership categories (state government owned, non-state government owned, and private).
Can a contractor that acts on behalf of the Medicaid agency submit the Upper Payment Limit (UPL) demonstrations to CMS?
No, the information must be submitted by the State Medicaid Director (or designated state official).
Are states required to submit their Upper Payment Limit (UPL) demonstrations directly to the mailbox or should they continue to submit them to the CMS Regional Office?
States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.
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.