CMS-10398 (#24) Clinic Standard Template

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

#24 - XIV - UPL-Clinic Template.xlsx

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

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

Overview

Disclosure
Overview & Instructions
Data Dictionary
Clinic


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 #24). 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 Clinic 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 Clinic UPL demonstrations.
For each facility, please complete the attached Clinic template.
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 separately 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:
CMS requests the following information for each Clinic:
- Demonstration Information asks for basic information such as the state, demonstration rate year, and service type (Clinic)
- 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), the clinic type, and the service-level category (i.e., CPT=Current Procedural Terminology)
- Cost or Medicare Payment Data asks for base year data relevant to the calculation of the UPL
- Medicaid Payment Data for Base Period asks for Medicaid charge 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
- 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 Clinic'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 Clinic 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 Clinic 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., Kentucky = KY) 0: Variables Included in Clinic Template
101 4-digit number State Demonstration Rate Year State demonstration rate year (e.g., 2014) 0: Variables Included in Clinic Template
102 6-character text Service Type Service type: Clinic = Clinic 0: Variables Included in Clinic Template
105 Unspecified Other State Provider ID Number State provider ID number that is not a MCD ID number (if applicable) 0: Variables Included in Clinic Template
112 6-digit number MCR Certification Number (MCR ID) MCR ID Number 0: Variables Included in Clinic Template
107 Unspecified State-specific Provider ID (MCD ID) MCD ID number 0: Variables Included in Clinic Template
108 Text Provider Name Provider name 0: Variables Included in Clinic Template
109 10-11 digit number National Provider ID (NPI) National Provider Identification Number 0: Variables Included in Clinic Template
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 Clinic Template
111 Text Clinic Type Description of Clinic Type (ASC= Ambulatory Surgery Centers, Dialysis, CMHC= Community Mental Health Center, Medical, BHC= Behavioral Health Center, Family Planning, County Health Department, Methadone, etc.) 0: Variables Included in Clinic Template
224 Text Source of UPL or Cost Report Data (MCR ASC Rates, Physician Fee Schedule, Cost Report, etc.) Specify source of UPL data used to calculate the Clinic UPL (MCR ASC Rates, Physician Fee Schedule, Cost Report, Cost-to-Charge ratio, Payment-to-Charge Ratio, etc.) 0: Variables Included in Clinic Template
200.1 Date [DD/MM/YYYY] MCR Fee Schedule or Cost Report Begin Date MCR fee schedule begin date or cost report begin date that is used to calculate the UPL 0: Variables Included in Clinic Template
200.2 Date [DD/MM/YYYY] MCR Fee Schedule or Cost Report End Date MCR fee schedule end date or cost report end date that is used to calculate the UPL 0: Variables Included in Clinic Template
203 $ Amount MCR or Other Costs Base year MCR or other costs used to calculate the UPL 0: Variables Included in Clinic Template
204 $ Amount MCR Charges Base year MCR charges, if using a cost-to-charge or payment-to-charge method, used to calculate the MCR Cost-to-Charge Ratio (CCR) or Payment-to-Charge Ratio (PTC) (Variable 208) 0: Variables Included in Clinic Template
205 $ Amount MCR Payments Base year MCR payments calculated from MCR fee schedules 0: Variables Included in Clinic Template
208 Proportion MCR Cost-To-Charge Ratio (CCR) or Payment-to-Charge Ratio (PTC) For CCR, calculated as MCR Costs (Variable 203) / MCR Charges (Variable 204). For PTC, calculated as MCR Payments (Variable 205) / MCR Charges (Variable 204) 0: Variables Included in Clinic Template
300.1 Date [DD/MM/YYYY] Time Period of MCD Charge and Payment Data - Begin Date Beginning date of base year MCD payment and charge data (if applicable) 0: Variables Included in Clinic Template
300.2 Date [DD/MM/YYYY] Time Period of MCD Charge and Payment Data - End Date End date of base year MCD payment and charge data (if applicable) 0: Variables Included in Clinic Template
301 $ Amount MCD Charges Total MCD Charges for the time period specified in variables 300.1 and 300.2, include if using a CCR or PTC method for determining UPL amount 0: Variables Included in Clinic Template
302 $ Amount MCD Regular Payments Total MCD non-supplemental payments for base year 0: Variables Included in Clinic Template
303.1 $ Amount MCD Supplemental Payments Total MCD supplemental payments for base year 0: Variables Included in Clinic Template
303.2 $ Amount MCD Supplemental Payments - GME/Training Total MCD supplemental payments for base year (GME=Graduate Medical Education/Training) 0: Variables Included in Clinic Template
303.3 $ Amount MCD Supplemental Payments - Other Total MCD supplemental payments for base year (Other) 0: Variables Included in Clinic Template
306 $ Amount Total MCD Payments Sum of MCD regular and supplemental payments for the base year 0: Variables Included in Clinic Template
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 Clinic Template
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 Clinic Template
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 Clinic Template
318 $ Amount Inflated MCD Payments to Demonstration Year Calculated as Total MCD Payments (Variable 306) x MCD Inflation Factor (Variable 308) x Other Adjustment to MCD Payments (Variable 309) 0: Variables Included in Clinic Template
400 $ Amount Calculated MCD UPL Amount Calculated UPL amount based on instructions provided in spreadsheet (i.e., Calculate as 205 if using MCR fee schedules, 203 if using cost reports, or 208 * 301 if using CCR or PTC method) 0: Variables Included in Clinic Template
404 Text UPL Inflation Factor Type Description of trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the rate year (e.g., Market Basket) 0: Variables Included in Clinic Template
405 Proportion UPL Inflation Factor Cumulative trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the rate year (note: 1.00= no change) (use "mid-point to mid-point approach") 0: Variables Included in Clinic Template
406 $ Amount Inflated UPL Amount Calculated as UPL Amount (Variable 400) x UPL Inflation Factor (Variable 405) 0: Variables Included in Clinic Template
401 $ Amount MCD Provider Tax Cost MCD provider tax costs can be added to the UPL separately, if using a cost-based demonstration 0: Variables Included in Clinic Template
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 Clinic Template
403 $ Amount Adjusted MCD UPL Amount Calculated as Inflated UPL Amount (Variable 406) + MCD Provider Tax Cost (Variable 401) + Other Adjustments to the UPL Amount (Variable 402) 0: Variables Included in Clinic Template
407 $ Amount UPL Gap Amount Calculated as Adjusted MCD UPL Amount (Variable 403) - Inflated MCD Payments to Demonstration Year (Variable 318) 0: Variables Included in Clinic Template
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 Clinic Template
409 $ Amount Adjusted UPL Gap Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408) 0: Variables Included in Clinic Template
End of Worksheet

Sheet 4: Clinic

This worksheet includes the template for completing Clinic 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 Clinic 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]
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:

Clinic Type




[111]
MCR Cost or Payment Info:

Source of UPL or Cost Report Data



[224]
MCR Cost or Payment Info:

UPL Source Data Begin Date


[200.1]
MCR Cost or Payment Info:

UPL Source Data End Date


[200.2]
MCR Cost or Payment Info:

Medicare Costs



[203]
MCR Cost or Payment Info:

Medicare Charges



[204]
MCR Cost or Payment Info:

Medicare Payments



[205]
MCR Cost or Payment Info:

Medicare Cost-To-Charge Ratio or Payment-To-Charge Ratio

[208]
MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - Begin Date

[300.1]
MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - End Date

[300.2]
MCD Charge and Payment Info:

Medicaid Charges



[301]
MCD Charge and Payment Info:

Medicaid Regular Payments


[302]
MCD Charge and Payment Info:

Medicaid Supplemental Payments


[303.1]
MCD Charge and Payment Info:

Medicaid Supplemental Payments (GME/Training)

[303.2]
MCD Charge and Payment Info:

Medicaid Supplemental Payments (Other)

[303.3]
MCD Charge and Payment Info:

Total Medicaid Payments



[306]
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 Medicaid Payments to Demonstration Year

[318]
UPL Calc Info:

Calculated Medicaid UPL Amount


[400]
UPL Calc Info:


UPL Inflation Factor Type



[404]
UPL Calc Info:

UPL Inflation Factor



[405]
UPL Calc Info:

Inflated UPL Amount



[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 KY 2015 Clinic A123456 1234567890 180000 34035324 EXAMPLE CLINIC Private ASC Physician Fee Schedule 7/1/2012 6/30/2013 $491,215 $475,680 $342,521 72.01% 7/1/2012 6/30/2013 $750,342 $546,445 $25,320 $25,320 $25,320 $571,765 None 1.000 1.030 $588,918 $342,521 Market Basket 1.055 $361,265 $15,320 $0 $376,585 -$212,332 $0 -$212,332
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