CMS-10398 (#13) Nursing Facility UPL Template

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

#13 - Attachment G -- NF Template.xlsx

Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

Document [xlsx]

Download: xlsx | pdf

Overview

Disclosure
Overview & Instructions
Data Dictionary
NF Cost
NF RUGs
NF Per Diem

Sheet 1: Disclosure

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #13). The time required to complete this information collection is estimated to average 40 per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Sheet 2: Overview & Instructions

This worksheet is for providing an overview and instructions for the Nursing Facility UPL Template. Use the arrow keys to read through the document.

Overview
States are required to demonstrate, and Centers for Medicare and Medicaid Services (CMS) has accepted a reasonable estimate of the Upper Payment Limit (UPL) based on a comparison of Medicaid (MCD) payments to equivalent Medicare (MCR) payment or Medicaid cost using Medicare principles. CMS has developed guidance documents to help states meet statutory and regulatory requirements that can be downloaded from:

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/accountability-guidance.html

CMS is also introducing templates specific to each service and demonstration type, which have been developed to assist states in meeting UPL requirements and increase comparability across states. This workbook contains templates for the nursing facility UPL demonstrations.

For each facility, please complete one of the following templates:
- NF Cost for cost-based demonstrations (e.g., routine per diem x Medicaid covered days)
- NF RUGs for Medicare Resource Utilization Groups (RUGs) -based demonstrations (acuity adjusted price-based demonstration)
- NF Per Diem for alternative demonstrations (e.g., case-mix adjusted Medicare payment per diem x Medicaid covered days)

States may apply different UPL formulas for state government owned or operated facilities, non-state government owned or operated facilities and private facilities; however, the formula should be consistently applied to each provider within the category. Additionally, each facility should only be included in one type of UPL demonstration. In filling out these templates, data for each individual provider should be included on a separate row. Additionally, all supplemental payments made by the state should be reported for each individual provider and reported separate from regular Medicaid payments. There may be instances where a variable is not applicable to your UPL calculation. Please leave these variables blank.

Information Requested:
Within each nursing facility UPL template, CMS requests the following information for each nursing facility:
- Demonstration Information asks for basic information such as the state, demonstration rate year, service type (nursing facility), and demonstration type (cost, RUGs, Per Diem)
- Provider Identification asks for provider identification numbers and names for each facility included, the ownership category type (private, non-state government owned, state-government owned), and whether the facility is classified as urban or rural
- Medicare Cost, RUGs, or Other Data for Base Period asks for Medicare base year data relevant to the calculation of the UPL
- Medicaid Payment and Utilization Data for Base Period asks for Medicaid utilization data used to calculate the UPL, as well as Medicaid payment data that is used to determine whether or not the state has made payments in excess of the UPL
- Medicaid Payments Inflated to Demonstration Year asks for inflationary or volume adjustment data that are made by the state to reflect changes in the Medicaid program that have occurred between the base and current rate year periods
- UPL Calculation & Inflation to Demonstration Year instructs the state to calculate the UPL and asks for inflationary adjustments to appropriately trend UPL data from the base to the current rate year
- Adjustments to UPL asks for other adjustments to the UPL that are not included in the UPL calculation (e.g., provider taxes for cost-based demonstrations)
- Calculation of UPL Gap instructs the state to calculate the UPL gap for each facility by subtracting (adjusted/inflated) Medicaid payments from the calculated UPL

Payment and Cost Data: Enter to the nearest dollar (i.e. $1,234,567.89 should be entered as $1,234,568)
Proportion and Percentage Data: Enter with no more than four decimal places (i.e., 0.12345 should be entered as 0.1235)

Detailed descriptions for each variable are provided in the next sheet labeled "Data Dictionary." A hypothetical nursing facility's data has also been entered for each template to provide guidance regarding the data requested for each column.

End of Worksheet

Sheet 3: Data Dictionary

This worksheet includes a data dictionary to assist in completing the Nursing Facility Template. The table includes the variable number, required variable format, a short description of the input variable, a longer and more detailed description of the variable, and a key for which of the template tabs the variable is used in. Use the arrow keys to read through the document.
Table 1. CMS UPL Nursing Facility Template Data Dictionary
Variable numbering scheme is used for internal identification of each variable and is not meant to be presented in numerical order
Variable Number	Variable Format	Short Description	Long Description	Variable Status
100	2-character text	State	2-character state ID (e.g., Maryland = MD)	0: Variables Included in All NF Templates
101	4-digit number	State Demonstration Rate Year	State demonstration rate year (e.g., 2014)	0: Variables Included in All NF Templates
102	2-character text	Service Type	Service type: NF= nursing facility	0: Variables Included in All NF Templates
104	Text	Demonstration Type (Cost, RUGs, Per Diem)	Demonstration type (Cost= Cost-based; RUGs= MCR Resource Utilization Group Payment-based; Per Diem= Per Diem-based (e.g., case-mix adjusted payment per diem)	0: Variables Included in All NF Templates
105	Text	Other State Provider ID Number	State provider ID number that is not a MCD ID number (if applicable)	0: Variables Included in All NF Templates
112	6-digit number	MCR Certification Number (MCR ID)	MCR ID Number	0: Variables Included in All NF Templates
107	Text	State-specific Provider ID (MCD ID)	MCD ID number	0: Variables Included in All NF Templates
108	Text	Provider Name	Provider name	0: Variables Included in All NF Templates
109	10-11 digit number	National Provider ID (NPI)	National Provider Identification Number	0: Variables Included in All NF Templates
110	Text	Ownership Category Type (Private, NSGO, SGO)	Ownership category type (private= private; NSGO= non-state government owned; SGO= state government owned)	0: Variables Included in All NF Templates
115	Text	Urban / Rural Location	MCR payment classification (Urban, Rural)	0: Variables Included in All NF Templates
300.1	Date [DD/MM/YYYY]	Time Period of MCD Days - Begin Date	Beginning date of base year MCD days (note: for cost-based demonstration, date should match MCR Cost Report data period)	0: Variables Included in All NF Templates
300.2	Date [DD/MM/YYYY]	Time Period of MCD Days - End Date	End date of base year MCD days (note: for cost-based demonstration, date should match MCR Cost Report data period)	0: Variables Included in All NF Templates
310	Number	MCD Days	MCD days corresponding to time period specified in Variables 300.1 and 300.2, used in calculating the UPL for the base period	0: Variables Included in All NF Templates
311.1	Date [DD/MM/YYYY]	Time Period of MCD Rates - Begin Date	Beginning date of MCD rates used to determine total MCD payments for purposes of comparing to the UPL	0: Variables Included in All NF Templates
311.2	Date [DD/MM/YYYY]	Time Period of MCD Rates - End Date	End date of MCD rates used to determine total MCD payments for purposes of comparing to the UPL	0: Variables Included in All NF Templates
312	$ Amount	MCD Regular Payment Per Diem	MCD regular payments per diem applicable to the dates specified in Variables 311.1 and 311.2	0: Variables Included in All NF Templates
313.1	$ Amount	MCD Supplemental Payment Per Diem	MCD supplemental payments per diem applicable to the dates specified in Variables 311.1 and 311.2	0: Variables Included in All NF Templates
313.2	$ Amount	MCD Supplemental Payment Per Diem - GME / Training	MCD supplemental payments per diem applicable to the dates specified in Variables 311.1 and 311.2 (GME=Graduate Medical Education / Training)	0: Variables Included in All NF Templates
313.3	$ Amount	MCD Supplemental Payment Per Diem - Other	MCD supplemental payments per diem applicable to the dates specified in Variables 311.1 and 311.2 (Other)	0: Variables Included in All NF Templates
314.1	$ Amount	Adjustment to MCD Per Diem #1	Adjustment to MCD payments per diem to account for services paid separately outside of the MCD NF rate, but reimbursed under the SNF PPS=Skilled Nursing Facility Prospective Payment System (e.g., drugs, therapy, lab, radiology)	0: Variables Included in All NF Templates
314.2	$ Amount	Adjustment to MCD Per Diem #2	Adjustment to MCD payments per diem to account for services paid separately outside of the MCD NF rate, but reimbursed under the SNF PPS (e.g., drugs, therapy, lab, radiology)	0: Variables Included in All NF Templates
317	$ Amount	Total MCD Regular and Supplemental Per Diem with Adjustments	Calculated as MCD Regular Payment Per Diem (Variable 312) + MCD Supplemental Payment Per Diem (Variable 313.1) + MCD Supplemental Payment GME/Training Per Diem (Variable 313.2) + MCD Supplemental Payment Other Per Diem (Variable 313.3) + Adjustment to MCD Per Diem #1 (Variable 314.1) + Adjustment to MCD Per Diem #2 (Variable 314.2)	0: Variables Included in All NF Templates
307	Text	MCD Inflation Factor Type	Description of MCD payment trend factor used to reflect changes in the MCD program between the base and current rate year periods (e.g., Market Basket)	0: Variables Included in All NF Templates
308	Proportion	MCD Inflation Factor	Cumulative MCD payment trend factor used to reflect changes in the MCD program between the base and current rate year periods (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All NF Templates
309	Proportion	Other Adjustment to MCD Payments	Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the MCD program between the base and current rate year periods (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All NF Templates
315	$ Amount	Inflated / Adjusted MCD Payment Per Diem	Calculated as Total MCD Regular and Supplemental Per Diem with Adjustments (Variable 317) x MCD Inflation Factor (Variable 308) x Other Adjustment to MCD Payments (Variable 309)	0: Variables Included in All NF Templates
316	$ Amount	Total MCD Payments (Per Diem * Days)	Calculated as Inflated / Adjusted MCD Payment Per Diem (Variable 315) x MCD Days (Variable 310)	0: Variables Included in All NF Templates
404	Text	UPL Inflation Factor Type	Description of trend factor used to inflate the UPL Per Diem Amount from the base year to the rate year (e.g., Market Basket)	0: Variables Included in All NF Templates
405	Proportion	UPL Inflation Factor	Cumulative trend factor used to inflate the Calculated MCD UPL Per Diem from the base year to the rate year (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All NF Templates
400	$ Amount	Inflated / Adjusted UPL Per Diem	Calculated Inflated / Adjusted UPL Per Diem based on instructions provided in spreadsheet (e.g., for cost-based demonstration: base year Adjusted Cost Per Diem (Variable 215) x UPL Inflation Factor (Variable 405)	0: Variables Included in All NF Templates
406	$ Amount	Inflated UPL Amount	Calculated as Inflated / Adjusted UPL Per Diem (Variable 400) x MCD Days (Variable 310)	0: Variables Included in All NF Templates
402	$ Amount	Other Adjustments to the UPL Amount	Adjustments made to the UPL that are not otherwise accounted for in the UPL calculation (e.g., adjustments for managed care transition)	0: Variables Included in All NF Templates
403	$ Amount	Adjusted MCD UPL Amount	Calculated as Inflated UPL Amount (Variable 406) + Other Adjustments to the UPL Amount (Variable 402) [+ MCD Provider Tax Cost (Variable 401) for cost-based demonstrations]	0: Variables Included in All NF Templates
407	$ Amount	UPL Gap Amount	Calculated as Adjusted MCD UPL Amount (Variable 403) - Inflated MCD Payments to Demonstration Year (Variable 316)	0: Variables Included in All NF Templates
408	$ Amount	Adjustment to the UPL Gap	Adjustments made to the UPL gap that are not otherwise accounted for in MCD payments or the UPL calculation	0: Variables Included in All NF Templates
409	$ Amount	Adjusted UPL Gap	Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408)	0: Variables Included in All NF Templates
215	$ Amount	Adjusted Cost Per Diem	Calculated as Per Diem Costs (Variable 211) + Adjustments to MCR Per Diem #1 (Variable 212.1) + Adjustments to MCR Per Diem #2 (Variable 212.2)	1: Variables Included in NF Cost Template But NOT Included Across All NF Templates
401	$ Amount	MCD Provider Tax Cost	For cost-based demonstrations, MCD provider tax costs can be added to the UPL separately	1: Variables Included in NF Cost Template But NOT Included Across All NF Templates
217	Text	MCR RUGs Type / Version	MCR RUG Type / Version used for assigning SNF PPS rates as defined by the number of groups (e.g., 44, 66)	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
218.1	Date [DD/MM/YYYY]	MCR RUGs Rate - Effective Begin Date	Beginning date of the MCR RUGs rate used for the purposes of calculating the UPL	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
218.2	Date [DD/MM/YYYY]	MCR RUGs Rate - Effective End Date	End date of the MCR RUGs rate used for the purposes of calculating the UPL	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
210	Number	MCR Days	Specify MCR days if used in calculation of RUGS rates	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
216	$ Amount	Average MCR RUGs Rate Per Diem	Weighted average MCR RUGs rate per diem for MCD days priced at SNF PPS rates	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
219.1	$ Amount	Adjustment #1 to RUGs Rate	Adjustment to MCR Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days)	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
219.2	$ Amount	Adjustment #2 to RUGs Rate	Adjustment to MCR Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days)	2: Variables Included in NF RUGs Template But NOT Included Across All NF Templates
207	Proportion	MCR Case Mix Index (CMI)	Average MCR Case Mix Index (CMI) for the facility (if used to calculate the UPL)	3: Variables Included in NF Per Diem Template But NOT Included Across All NF Templates
305	Proportion	MCD Case Mix Index (CMI)	Average MCD Case Mix Index (CMI) for the facility	3: Variables Included in NF Per Diem Template But NOT Included Across All NF Templates
410	$ Amount	Calculated MCD UPL Per-diem	Calculated as Adjusted Per Diem Payments (Variable 222) x [MCD Case Mix Index (Variable 305) / MCR Case Mix Index (Variable 305)]	3: Variables Included in NF Per Diem Template But NOT Included Across All NF Templates
200.1	Date [DD/MM/YYYY]	MCR Cost Report Begin Date	MCR Cost Report begin date of MCR data provided that is used to calculate the UPL	4: Variables Included in NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
200.2	Date [DD/MM/YYYY]	MCR Cost Report End Date	MCR Cost Report end date of MCR data provided that is used to calculate the UPL	4: Variables Included in NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
202	Text	MCR Cost Report Filing Status	MCR Cost Report filing status (filed or settled)	4: Variables Included in NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
211	$ Amount	MCR Per Diem	In NF Cost Template, cost per diem used to calculate the UPL from the cost report period specified in Variables 200 and 201 In NF Per Diem Template, payment per diem used to calculate the UPL from the cost report period specified in Variables 200.1 and 200.2	4: Variables Included in NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
212.1	$ Amount	Adjustments to MCR Per Diem #1	For NF Cost Template, adjustment to MCR Cost Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days) For NF Per Diem Template, adjustment to MCR Payment Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days)	4: Variable Included in the NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
212.2	$ Amount	Adjustments to MCR Per Diem #2	For NF Cost Template, adjustment to MCR Cost Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days) For NF Per Diem Template, adjustment to MCR Payment Per Diem to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days)	4: Variable Included in the NF Cost and NF Per Diem Templates But NOT Included in the NF RUGs Template
222	$ Amount	Adjusted MCR Per Diem	In NF RUGs Template, calculated Adjusted MCR Per Diem: Average MCR RUGs Rate Per Diem (Variable 216) + Adjustment #1 to RUGs Rate (Variable 219.1) + Adjustment #2 to RUGs Rate (Variable 219.2) In NF Per Diem Template, calculated Adjusted MCR Per Diem: MCR Payments Per Diem (Variable 211) + Adjustments to MCR Per Diem #1 (Variable 212.1) + Adjustments to MCR Per Diem #2 (Variable 212.2)	4: Variables Included in NF RUGs and NF Per Diem Templates But NOT Included in the NF Cost Template
End of Worksheet

Sheet 4: NF Cost

This worksheet includes the template for completing Nursing Facility UPL for a Costs basis. The first line of the template includes the type of information collected (for example, Provider Information), the short variable description, and the variable number. The Data Dictionary, located in Table 1 of the Data Dictionary Worksheet, can be for additional information in completing this template. The first data row of the NF Cost template includes examples of inputs as assistance in completing this template. Use tab to move to input areas. Use the arrow keys to read through the document.

Database Description &

Variable Number

Demo Info:

State

[100]

Demo Info:

State Demonstration Rate Year

[101]

Demo Info:

Service Type

[102]

Demo Info:

Demonstration Type

[104]

Provider Info:

Other State Provider ID Number

[105]

Provider Info:

National Provider ID (NPI)

[109]

Provider Info:

Medicare Certification Number
(Medicare ID)

[112]

Provider Info:

State-specific Provider ID (Medicaid ID)

[107]

Provider Info:

Provider Name

[108]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Urban / Rural Location

[115]

MCR or Other Cost Info:

Medicare Cost Report Begin Date

[200.1]

MCR or Other Cost Info:

Medicare Cost Report End Date

[200.2]

MCR or Other Cost Info:

Medicare Cost Report Filing Status

[202]

MCR or Other Cost Info:

Medicare Per Diem

[211]

MCR or Other Cost Info:

Adjustments to Medicare Per Diem #1

[212.1]

MCR or Other Cost Info:

Adjustments to Medicare Per Diem #2

[212.2]

MCR or Other Cost Info:

Adjusted Per Diem Costs

[215]

MCD Payment and Utilization Info:

Time Period of Medicaid Days - Begin Date

[300.1]

MCD Payment and Utilization Info:

Time Period of Medicaid Days - End Date

[300.2]

MCD Payment and Utilization Info:

Medicaid Days

[310]

MCD Payment and Utilization Info:

Time Period of Medicaid Rates - Begin Date

[311.1]

MCD Payment and Utilization Info:

Time Period of Medicaid Rates - End Date

[311.2]

MCD Payment and Utilization Info:

Medicaid Regular Payment Per Diem

[312]

MCD Payment and Utilization Info:

Medicaid Supplemental Payment Per Diem

[313.1]

MCD Payment and Utilization Info:

Medicaid Supplemental Payment Per Diem
(GME/Training)

[313.2]

MCD Payment and Utilization Info:

Medicaid Supplemental Payment Per Diem
(Other)

[313.3]

MCD Payment and Utilization Info:

Adjustment to Medicaid Per Diem #1

[314.1]

MCD Payment and Utilization Info:

Adjustment to Medicaid Per Diem #2

[314.2]

MCD Payment and Utilization Info:

Total Medicaid Regular and Supplemental Per Diem with Adjustments

[317]

MCD Inflated Payment Info:

MCD Inflation Factor Type

[307]

MCD Inflated Payment Info:

MCD Inflation Factor

[308]

MCD Inflated Payment Info:

Other Adjustment to Medicaid Payments

[309]

MCD Inflated Payment Info:

Inflated / Adjusted Medicaid Payment Per Diem

[315]

MCD Inflated Payment Info:

Total Medicaid Payments

[316]

UPL Calc Info:

UPL Inflation Factor Type

[404]

UPL Calc Info:

UPL Inflation Factor

[405]

UPL Calc Info:

Inflated / Adjusted UPL Per Diem

[400]

UPL Calc Info:

Inflated UPL Amount - UPL Per Diem * Medicaid Days

[406]

UPL Adjustment Info:

Medicaid Provider Tax Cost

[401]

UPL Adjustment Info:

Other Adjustments to the UPL Amount

[402]

UPL Adjustment Info:

Adjusted Medicaid UPL Amount

[403]

UPL Gap Info:

UPL Gap Amount

[407]

UPL Gap Info:

Adjustment to the UPL Gap

[408]

UPL Gap Info:

Adjusted UPL Gap

[409]

EXAMPLE

2015

Cost

RA53433

1234567890

210000

65745234

EXAMPLE NURSING FACILITY

Private

Urban

7/1/2012

6/30/2013

Filed

$210.11

$2.51

$0.67

$213.29

7/1/2012

6/30/2013

3,124

7/1/2014

6/30/2015

$185.00

$4.80

$1.20

$0.00

$200.60

None

1.000

$200.60

$626,674

Market Basket

1.055

$225.02

$702,965

$130,000

$832,965

$206,291

No Data

End of Worksheet

Sheet 5: NF RUGs

This worksheet includes the template for completing Nursing Facility UPL for a Costs basis. The first line of the template includes the type of information collected (for example, Provider Information), the short variable description, and the variable number. The Data Dictionary, located in Table 1 of the Data Dictionary Worksheet, can be for additional information in completing this template. The first data row of the NF RUGs template includes examples of inputs as assistance in completing this template. Use tab to move to input areas. Use the arrow keys to read through the document.

Database Description &

Variable Number

Demo Info:

State

[100]

Demo Info:

State Demonstration Rate Year

[101]

Demo Info:

Service Type

[102]

Demo Info:

Demonstration Type

[104]

Provider Info:

Other State Provider ID Number

[105]

Provider Info:

National Provider ID (NPI)

[109]

Provider Info:

Medicare Certification Number
(Medicare ID)

[112]

Provider Info:

State-specific Provider ID (Medicaid ID)

[107]

Provider Info:

Provider Name

[108]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Urban / Rural Location

[115]

MCR RUGs Info:

Medicare RUGs Type / Version

[217]

MCR RUGs Info:

Medicare RUGs Rate - Effective Begin Date

[218.1]

MCR RUGs Info:

Medicare RUGs Rate - Effective End Date

[218.2]

MCR RUGs Info:

Medicare Days

[210]

MCR RUGs Info:

Average Medicare RUGs Rate Per Diem

[216]

MCR RUGs Info:

Adjustment #1 to RUGs Rate

[219.1]

MCR RUGs Info:

Adjustment #2 to RUGs Rate

[219.2]

MCR RUGs Info:

Adjusted Medicare RUGs Per Diem

[222]