CMS-10398 #24 XIV - Clinic Template

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

#24 - Mediciad UPL-Clinic 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⚠️ Notice: This form may be outdated.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:

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Overview

Overview & Instructions
Data Dictionary
Clinic

Sheet 1: 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 2: 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 3: 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

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

$571,765

None

1.000

1.030

$588,918

$342,521

Market Basket

1.055

$361,265

$15,320

$376,585

-$212,332

No Data

End of Worksheet

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