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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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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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Our state uses multiple cost centers with varying cost-to-charge ratios in our calculation of the inpatient hospital Upper Payment Limit (UPL). Does the template accommodate this?

Yes, the template allows the use of multiple cost centers with multiple cost-to-charge ratios. The state would separately report the costs and payments associated with each of the cost centers in the cost template. To differentiate the cost centers, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, for example an -A, -B, or -C, that would be used as a unique identifier for each cost center.

FAQ ID:92266

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The Inpatient Hospital Services (IPH), Outpatient Hospital Services (OPH), and Nursing Facility (NF) templates do not include fields to sum the Upper Payment Limit (UPL) gap by ownership category (private, Non-State Governmental Organization (NSGO), State Government Ownded (SGO). How should these totals be presented in the template?

The total UPL gap by ownership category can be shown by inserting a new tab in the file with these calculations, unless a summary worksheet is already included in the workbook. If there are any questions about how to add this tab, please reach out to your CMS Regional Office or send a follow-up question (with your template) to the UPL mailbox and additional guidance will be provided.

FAQ ID:92281

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