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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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Our state uses multiple methodologies for the three ownership categories in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple methodologies?

Yes, the templates allow the use of multiple methodologies. The state would complete the templates associated with the UPL methodologies used. For example, if the state uses a cost-based methodology for state owned hospitals and a payment-based methodology for private hospitals, then the state would complete the cost template for the state owned hospitals and the payment template for the private hospitals. When using multiple methodologies, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.

FAQ ID:92271

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How is the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) different from other institutional UPLs?

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

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Is the state required to report in the Psychiatric Residential Treatment Facility (PRTF) Upper Payment Limit (UPL) template the number of service days for Medicaid beneficiaries?

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

FAQ ID:92421

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