Frequently Asked Questions

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.

FAQ ID:92446

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.

FAQ ID:92456

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.

FAQ ID:92431

When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.

FAQ ID:92221

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

The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.

FAQ ID:92231

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).

FAQ ID:92236

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

No, the information must be submitted by the State Medicaid Director (or designated state official).

FAQ ID:92246

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.

FAQ ID:92251