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 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
Are there exclusions for the Long Term Services and Supports Admission to an Institution from the Community measure's eligible population (denominator)?
No. However, when identifying the measure’s denominator from the eligible population, there are a few cases in which you should not include member months. For example, do not include months when the plan member was residing in an institutional facility for the entire month (that is, there were no days in the month spent residing in the community). If a member died, do not include the month during which the member died and any subsequent months of enrollment in the measure’s denominator.
Are there exclusions for the Long Term Services and Supports Admission to an Institution from the Community measure's numerator?
When calculating the measure’s numerator (number of admissions to an institution), do not include admissions that are direct transfers from another institution, admissions from the hospital that originated from an institution, or admissions for individuals who do not meet the continuous enrollment criteria. If the member’s admission resulted in death in the institution or death within one day of discharge from the institution, do not include the admission in the numerator.
Can the community residence include assisted living?
Yes, people admitted to an institution who were residing in the community prior to their admission may include those residing in assisted living, adult foster care, or another setting that is not defined as an institution.
Is the Long Term Services and Supports Admission to an Institution from the Community measure risk-adjusted?
Yes, this measure is risk-adjusted, using risk stratification by age. Results are reported separately for four age groups (18-64, 65-74, 75-84, 85 and older) for each of the length of stay classifications (short-term stay, medium-term stay, and long-term stay).
When a facility has been in operation for the dates of service covered by the Upper Payment Limit (UPL) demonstration, can a state demonstrate the UPL by using less than 12 months of data?
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.
What data should my state provide to the Centers for Medicare & Medicaid Services (CMS) for the annual Upper Payment Limit demonstrations?
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.
Can you explain the difference between a prospective Upper Payment Limit (UPL) and a retrospective UPL?
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.
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.
When a state pays at or less than the Medicare rate is it required to submit an Upper Payment Limit (UPL) demonstration using the template(s)?
No, if a state's payment methodology describes payment at no more than 100 percent of the Medicare rate for the period covered by the UPL then it does not need to submit a demonstration using the template(s). To show the state has met the annual UPL demonstration reporting requirement it should make CMS aware that it is paying no more than the Medicare rate.
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.