Payment Limit Demonstrations

Required Upper Payment Limit Demonstrations

State Medicaid Director Letter (SMDL) 13-003 requires states to annually submit Upper Payment Limit (UPL) demonstrations. To assist states in meeting this requirement, the Centers for Medicare & Medicaid Services (CMS) created reporting templates. These templates help standardize data collection and, through the use of embedded formulas, promote efficient reporting by states. Accompanying each template are instructions and a data dictionary that defines reporting variables.

Authority to collect information using the OMB-approved UPL Templates

The regulations at 42 CFR § 431.16(a) require the state Medicaid agency to submit all reports required by the Health & Human Services (HHS) Secretary (the Secretary). In addition, the regulations at 42 CFR § 431.16(b) specify that the state Medicaid agency must follow the Secretary’s instruction with regard to the form and the content of those reports. The templates are collections of information which have been authorized by the Office of Management and Budget (OMB) and the Secretary. The Paperwork Reduction Act (PRA) process followed by CMS to receive OMB approval of the UPL templates required Secretarial clearance. This clearance, in conjunction with these regulations, require states to submit their UPL demonstrations using the templates. When using these templates, states will continue to have the same flexibilities with regard to demonstrating their UPL. The UPL templates ensure states are demonstrating UPLs in a uniform manner. Standardization of UPL reporting will promote faster processing of UPL demonstrations by CMS and enhance Federal/State fiscal oversight of the Medicaid program.

Timeframe for use of the UPL reporting templates

Beginning in state fiscal year (SFY) 2019, CMS will require states to submit UPL demonstrations using the OMB-approved templates for the following services:

  • Inpatient Hospital Services
  • Outpatient Hospital Services
  • Nursing Facility Services
  • Institutions for Mental Disease (IMD)
  • Clinic Services
  • Intermediate Care Facility for the Individuals with Intellectual Disabilities (ICF/IID)
  • Psychiatric Residential Treatment Facility (PRTF)
  • Qualified Practitioner Services (for states that pay targeted supplemental payments)

To meet the annual reporting requirement, states have the option to:

  1. Submit a prospective UPL demonstration at the beginning of the state fiscal year
  2. Submit a UPL demonstration during the state fiscal year, when modifying a payment methodology
  3. Submit a retrospective demonstration at the end of the state fiscal year

Previously, states have provided UPL demonstrations only when modifying payment subject to the UPL.

As discussed in SMDL 13-003, the documents below assist states in developing upper payment limit demonstrations that are consistent with the regulations and federal policies. In addition to the OMB approved templates, states must submit any data and narrative description necessary to support their UPL demonstrations.  

Materials for UPL Submissions

UPL demonstrations must be submitted by the state within each state fiscal year for the services below:  

Inpatient Hospital Service

Institutions of Mental Disease

Outpatient Hospital Services

Nursing Facility Services

Clinic Services

Intermediate Care Facility for Individuals with Intellectual Disabilities

Psychiatric Residential Treatment Facility

Qualified Practitioner Services Average Commercial Rate

For questions related to UPL submissions, please see the UPL Demonstrations Questions and Answers. If your question is not addressed within the UPL Demonstration Questions and Answers, please direct your question to the CMS resource mailbox at: MedicaidUPL@cms.hhs.gov.

Federal Financial Participation Limits for Durable Medical Equipment

On December 27, 2017, CMS released a now updated SMDL 18-001 to provide policy guidance to states on compliance with the statutory limit on available federal financial participation (FFP) for State Medicaid expenditures for Durable Medical Equipment (DME) authorized by section 1903(i)(27) of the Social Security Act (the Act) as established by section 503 of the Consolidated Appropriations Act, 2016 and further amended by section 5002 of the 21st Century Cures Act of 2016. Per the statute, the changes are effective on January 1, 2018. Below are the appendices discussed in the SMDL, offering some additional information related to state compliance options.

For questions related to compliance with the statutory limit on available federal financial participation (FFP) for State Medicaid expenditures for Durable Medical Equipment (DME), please direct your question to the CMS resource mailbox at: MedicaidDME@cms.hhs.gov.