CMS-10398 #24 XII. Intermediate Care Facilitiy Template

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

24 - XII - UPL-Intermediate-Care-Facility Template.xlsx

GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers

OMB: 0938-1148

⚠️ Notice: This form may be outdated.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

Document [xlsx]

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Overview

Overview & Instructions
Disclosure
Data Dictionary
ICF

Sheet 1: Overview & Instructions

This worksheet is for providing an overview and instructions for the Intermediate Care 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 as 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 Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) UPL demonstrations.

For each facility, please complete the attached 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, any 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 ICF/IID facility:
- Demonstration Information asks for basic information such as the state, demonstration rate year, service type (ICF/IID), and demonstration type (cost, other)
- Provider Identification asks for provider identification numbers and names for each facility included, and the ownership category type (private, non-state government owned, state-government owned)
- Medicare or Other Cost 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 and/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 amount and asks for inflationary adjustments to appropriately trend UPL amounts 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)
- 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 ICF/IID's data has also been entered for each template to provide guidance regarding the data requested for each column.

End of Worksheet

Sheet 2: 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 3: Data Dictionary

This worksheet includes a data dictionary to assist in completing the Intermediate Care 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 Intermediate Care 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 ICF Template
101	4-digit number	State Demonstration Rate Year	State demonstration rate year	0: Variables Included in ICF Template
102	7-character text	Service Type	Service type: ICF/IID = Intermediate Care Facility for Individuals with Intellectual Disabilities	0: Variables Included in ICF Template
104	Text	Demonstration Type (Cost/Other)	Demonstration type (Cost= Cost-based)	0: Variables Included in ICF 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 ICF Template
112	6-digit number	MCR Certification Number (MCR ID)	MCR ID Number	0: Variables Included in ICF Template
107	Unspecified	State-specific Provider ID (MCD ID)	MCD ID number	0: Variables Included in ICF Template
108	Text	Provider Name	Provider name	0: Variables Included in ICF Template
109	10-11 digit number	National Provider ID (NPI)	National Provider Identification Number	0: Variables Included in ICF 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 ICF Template
224	Text	Source of UPL or Cost Report Data	Description of source for UPL or cost report data used to calculate the ICF/IID UPL (e.g., State Cost Report)	0: Variables Included in ICF Template
200.1	Date [DD/MM/YYYY]	MCR Cost Report Begin Date	MCR rate or Cost Report begin date of data provided that is used to calculate the UPL	0: Variables Included in ICF Template
200.2	Date [DD/MM/YYYY]	MCR Cost Report End Date	MCR rate or Cost Report end date of data provided that is used to calculate the UPL	0: Variables Included in ICF Template
211	$ Amount	MCR Per Diem	Per diem cost or MCR equivalent rate used to calculate the UPL from the period specified in Variables 200 and 201	0: Variables Included in ICF Template
212.1	$ Amount	Adjustments to MCR Per Diem #1	Adjustment to MCR Per Diem (if used) to account for services not included in the MCR SNF =Skilled Nursing Facility rate but reimbursed by the MCD program (e.g., leave of absence days)	0: Variables Included in ICF Template
212.2	$ Amount	Adjustments to MCR Per Diem #2	Adjustment to MCR Per Diem (if used) to account for services not included in the MCR SNF rate but reimbursed by the MCD program (e.g., leave of absence days)	0: Variables Included in ICF Template
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)	0: Variables Included in ICF Template
300.1	Date [DD/MM/YYYY]	Time Period of MCD Days - Begin Date	Beginning date of base year MCD days (note: should match MCR Cost Report data period)	0: Variables Included in ICF Template
300.2	Date [DD/MM/YYYY]	Time Period of MCD Days - End Date	End date of base year MCD days (note: should match MCR Cost Report data period)	0: Variables Included in ICF Template
310	Number	MCD Days	MCD days from time period specified in Variables 300.1 and 300.2, used in calculating the UPL for the base period	0: Variables Included in ICF Template
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 (these dates may differ from period used for days)	0: Variables Included in ICF Template
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 (these dates may differ from period used for days)	0: Variables Included in ICF Template
312	$ Amount	MCD Regular Payment Per Diem	MCD regular payments per diem applicable to the period specified in Variables 311.1 and 311.2	0: Variables Included in ICF Template
313.1	$ Amount	MCD Supplemental Payment Per Diem	MCD supplemental payments per diem applicable to the period specified in Variables 311.1 and 311.2	0: Variables Included in ICF Template
313.2	$ Amount	MCD Supplemental Payment Per Diem - GME / Training	MCD supplemental payments per diem applicable to the period specified in Variables 311.1 and 311.2 (GME=Graduate Medical Education / Training)	0: Variables Included in ICF Template
313.3	$ Amount	MCD Supplemental Payment Per Diem - Other	MCD supplemental payments per diem applicable to the period specified in Variables 311.1 and 311.2 (Other)	0: Variables Included in ICF Template
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 ICF/IID rate, but reimbursed under MCR (e.g., drugs, therapy, lab, radiology)	0: Variables Included in ICF Template
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 ICF/IID rate, but reimbursed under MCR (e.g., drugs, therapy, lab, radiology)	0: Variables Included in ICF Template
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 ICF Template
307	Text	MCD Inflation Factor Type	Description of payment/cost 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 ICF Template
308	Proportion	MCD Inflation Factor	Cumulative payment/cost 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 ICF 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 ICF Template
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 ICF Template
316	$ Amount	Total MCD Payments (Per Diem * Days)	Calculated as Inflated / Adjusted Total MCD Payment Per Diem (Variable 315) x MCD Days (Variable 310)	0: Variables Included in ICF Template
404	Text	UPL Inflation Factor Type	Description of payment/cost 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 ICF Template
405	Proportion	UPL Inflation Factor	Cumulative payment/cost 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 ICF Template
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 ICF Template
406	$ Amount	Inflated UPL Amount	Calculated as Inflated / Adjusted UPL Per Diem (Variable 400) x MCD Days (Variable 310)	0: Variables Included in ICF Template
401	$ Amount	MCD Provider Tax Cost	For cost-based demonstrations, MCD provider tax costs can be added to the UPL separately	0: Variables Included in ICF 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 ICF Template
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 ICF Template
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 ICF 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 ICF Template
409	$ Amount	Adjusted UPL Gap	Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408)	0: Variables Included in ICF Template
End of Worksheet

Sheet 4: ICF

This worksheet includes the template for completing Intermediate Care Facility Standard 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 ICF 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]

MCR or Other Cost Info:

Source of UPL or Cost Report Data

[224]

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 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

ICF/IID

Cost

RA53433

1234567890

210000

65745234

EXAMPLE ICF/IID

Private

State Cost Report

7/1/2012

6/30/2013

$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

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