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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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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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Should the period of time covered by the Upper Payment Limit (UPL) demonstration be tied to the state's fiscal year?

No, CMS does not require any particular starting point within the fiscal year for the UPL demonstrations. This allows states the flexibility to develop UPL demonstrations that are tied to the provider payment periods described in the state plan payment methodologies for each service. For instance, if a state submits a state plan amendment to update provider payments as of October 1 of each year, the state would document that the SPA changes comply with the UPL for the period 10/1 - 9/30 of that payment year. The UPL must represent the entire payment year. Since UPL demonstrations usually rely on historic data that is projected into a payment year, this is consistent with past practices.

FAQ ID:92226

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Can states that pay for inpatient hospital services using Diagnosis Related Grous (DRGs), but historically used a cost-based UPL, continue to use the cost-based Upper Payment Limit (UPL) method?

Yes, states may use UPL methodologies that are different from their payment methodologies. For example, a state may pay for inpatient hospital services using a Medicaid APR-DRG methodology, but use a cost methodology to compute the Medicare upper payment limit for its UPL demonstration.

FAQ ID:92386

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