Frequently Asked Questions

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

When a hospital acquires another hospital, the state should use all available data to determine the UPL and work with CMS to assure appropriate reporting. When a hospital ceases operation, the state should not annualize data if it does not cover a 12-month period.

FAQ ID:92391

The UPL limits payment to the Medicare rate or cost. Providers paid at cost may receive no more than their reconciled amount. As a result, states cannot attribute the "UPL room" from other providers to pay additional amounts to any provider paid at cost. Due to this payment limitation, states should not include any provider paid at cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at cost and, therefore, excluded from the calculation of the UPL.

FAQ ID:92396

Section 1903(i)(7) of the Social Security Act specifies a separate UPL for CDL services which limits payment to no more than the Medicare rate on a per test basis. To meet the statutory provision, the UPL for CDL services must be separately demonstrated from the OPH services UPL. States do not have the ability to "borrow room" from the CDL UPL and apply it to the OPH UPL.

FAQ ID:92401

Yes, a state may choose between using all-payer data or Medicare-specific data from the Medicare Hospital Cost Report (CMS Form 2552) to determine the cost-to-charge ratios.

FAQ ID:92406

To date, CMS has not published a list of revenue codes that must be included or excluded from this service category.  Medicaid outpatient hospital services are defined at 42 Code of Federal Regulations (CFR) 440.20 and include “preventive, diagnostic, therapeutic, rehabilitative, or palliative services”.  In the state plan, states further define those services covered as outpatient hospital services.

FAQ ID:92411

Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.

FAQ ID:92416

Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.

FAQ ID:92421

The UPL data for out of state providers does not need to be included in the UPL demonstration. If the state has provider level data then it may include it in the demonstration within the private ownership category of providers.

FAQ ID:92426

Many Medicaid beneficiaries living with dementia and other conditions can have a heightened risk of wandering, or attempting to leave a setting (exit-seeking) unsafely. These behaviors are not necessarily constant or permanent.

Wandering occurs in ways that may appear aimless but often have purpose. People may wander simply because they want to move. Sometimes wandering responds to an unmet basic need like human contact, hunger, or thirst; a noisy or confusing environment; or because people are experiencing some type of distress, like pain or the need to use the toilet. Wandering can be helpful or dangerous, depending on the situation. Although people who wander may gain social contact, exercise, and stimulation, they can also become lost or exhausted.

Person-centered planning, staff training and care delivery are core components of provider operations to meet HCBS requirements while responding to unsafe wandering and exit-seeking behavior in an individualized manner.3 Person-centered services involve knowing individuals, and their conditions, needs, and history and using this knowledge to create strategies to assure that individuals are free to interact with others and the community in the most integrated way possible and still prevent injury for those who wander or exit-seek unsafely. Home and community-based settings must demonstrate that person-centered planning drives their operations and services for each person. The beneficiaries the settings serve must drive the person-centered planning process with assistance from a trained, competent, assessor, care manager or similar facilitator. The beneficiary should be able to get input from people who are important to him or her, while still reflecting the individual's input as much as possible. Person-centered plans and related decisions should be consistent with the person's needs and preferences, and informed by family members, caregivers, and other individuals that the beneficiary has identified as playing an important role in his or her life. The role of person-centered planning and the process for realizing this role is described in the final HCBS regulation and in guidance found on the Medicaid.gov website.

Person-centered service plans should be developed with the individual, and include their representatives as appropriate. The person-centered planning process should include a process that:

• is informed by discussions with family members or other individuals who are important to them about key aspects of daily routines and rituals;
• focuses on an individual's strengths and interests;
• outlines the individual's reaction to various communication styles;
• identifies the individual's favorite things to do and experience during the day, as well as experiences that contribute to a bad day;
• proposes experiences that the person may enjoy as community engagement, and describes those factors or characteristics that the individuals would find most isolating or stigmatizing

To promote effective communication, which is at the core of person-centered planning and service delivery, provider staff serving beneficiaries who wander or exit-seek should receive education and training about how to communicate with individuals living with conditions that may lead to unsafe wandering or exit-seeking. Training programs may include important information on issues such as:

• The most common types of conditions, diseases and disorders that lead to wandering behavior; the various stages of key conditions that result in increased risk of wandering and what to expect over time; and the potential impact of these conditions on the individual's ability to function.
• Differentiating between most common types of conditions, diseases and disorders that lead to wandering behavior from serious mental illness or adverse environmental conditions such as overmedication or neglect.
• Assessing individuals for co-occurring conditions (including barriers to sufficient adaptive skills and the ability to communicate with others) that increase risk for unsafe wandering or exit-seeking.
• Understanding situations that led to past instances of unsafe wandering or exit-seeking or the desire to engage in them;
• Principles of person-centered care planning and service delivery;
• Strategies for identifying and handling behavioral expressions of need or distress.

In addition to previous guidance provided by CMS on the implementation of person-centered planning requirements outlined in the federal HCBS regulations defining home and community-based settings, integration of the following promising practices around person-centered planning specifically for people who wander or exit-seek unsafely is recommended:

• Assessing the patterns, frequency, and triggers for unsafe wandering or exit-seeking through direct observation and by talking with the person exhibiting such behaviors, and, when appropriate, their families.
• Using this baseline information to develop a person-centered plan to address unsafe wandering or exit-seeking, implementing the plan, and measuring its impact.
• Using periodic assessments to update information about an individual's unsafe wandering or exit-seeking, and adjust the person-centered plan as necessary.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)

FAQ ID:94926