Crosswalk-Guidance-Instructions (inpatient hospital, outpatient hospital, and nursing facility)

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Overview

Inpatient
Outpatient
Nursing Facility

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Sheet 1: Inpatient

No.	UPL Inpatient Hospital Guidance Questions in MACFin System	Original Document (PRA completed in January 2021)	Explanation	Burden Change
Section I. UPL Demonstration
1	Are there any significant changes to the prior year UPL methodology?	I. The Basis of the UPL Formula is: 0 Cost-Based Demonstration (e.g. Cost-to-charge ratio X Medicaid covered I/P charges) or 0 Payment-Based Demonstration (e.g. Payment-to-charge ratio X Medicaid covered I/P charges) 0 Medicare DRG (Acuity-Adjusted Price-Based Demonstration)	CMS folded the Old Guidance & Instructions documents into 1 online form that asks questions that before were open text boxes that states had to fill in to explain their methodology. Here the crosswalk includes any changes.	No
2	Does the UPL demonstration align with your state fiscal year?	0 Other (please describe below): Open text box		No
3	Does the UPL demonstration trend data from the previous UPL demonstration submission or does it contain new data? If using trended data, please specify which data variables are trended.	0 Other (please describe below): Open text box		No
4	Does the UPL demonstration include a full 12 months of data for each provider?	Please provide a general description of the formula: Open text box		No
5	Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period?	Please provide a general description of the formula: Open text box		No
6	Does this UPL demonstration include Institutions for Mental Disease (IMDs)?	0 Other (please describe below): Open text box		No
7	Has the provider count (providers enrolled in the Medicaid program and included in the UPL demonstration) changed from the previous UPL demonstration?	0 Other (please describe below): Open text box		No
7a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	0 Other (please describe below): Open text box		No
7b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	0 Other (please describe below): Open text box		No
8	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for inpatient hospital services.	0 Other (please describe below): Open text box		No
Section II. The Medicare Equivalent Data
1	What is the source of the Medicare Equivalent Data (200-level series variables in the template)?	II. The source of the UPL Medicare Equivalent Data is: 0 The Medicare Cost Report (CMS 2552-96 or 2552-10) 0 Filed 0 Settled		No
1a	Does the state have separate DRG amounts for state, non-state government, and private ownership categories?	Does the state have separate DRG amounts for state, non-state government, and private providers? 0 Yes 0 No		No
1b	Describe the methodology for calculating the DRG UPL (variables 205.1, 205.2, 207& 305, as calculated in variable 400 - the unadjusted UPL).	Were all claims included in the DRG demonstration or a sample? 0 Yes 0 No Explain the sample and the basis for using sampling: Describe the application of the DRG:		No
1c	Explain the pricer factors and how they tie to what Medicare has established for the providers in the base year.	Please explain the pricer factors and how they tie to what Medicare has established for the providers in the base year. Also explain how mother and baby days are handled.		No
1d	Does the State calculate a per discharge amount per facility? (variables 205.1, 205.2, 206, & 207)	0 The State calculates a per discharge amount per facility Is the per discharge amount run through the Medicare grouper? 0 Yes 0 No Please detail the calculation of the per discharge amount.		No
2	How does the Medicare PPS demonstration adjusts for differences in Medicare and Medicaid patient acuity?	No change		No
3	What are the other data source(s) used in the UPL calculation?	0 Please explain all other data source(s) used in the UPL calculation.		No
4	What is the time period of the data?	What is the time period of the data? Base year data: _________________________ Rate year data: _________________________		No
Section III. The State uses the Cost Report References below:
1	Cost-Based Demonstration (e.g., Ancillary Cost-to-Charge Ratio and Room and Board Per Diem)	III. The State uses the Cost Report References below: Cost-Based Demonstration (e.g. Ancillary Cost-to-Charge Ratio and Room and Board per Diems): 0 Worksheet B 0 Worksheet C 0 Worksheet D-1 Describe which columns and lines that are used to determine the cost-to-charge ratios and, if applicable, the hospital routine per diem amounts used in the cost-based UPL.		No
2	Payment-to-Charge Demonstration (Payment to Charge Ratio) used	Payment-to-Charge Demonstration (Payment to Charge Ratio) use: 0 Worksheet E, Part A (Payments) / Worksheet D-4 (Charges) Describe which worksheets, columns and lines that are used to determine the Medicare payments and charges to calculate the payment-to-charge ratio(s).		No
3	Does the Medicare payment data represent gross reported payment, or are adjustments made to the data to capture the net payment?	No change		No
	No Question	Please describe all other cost report worksheets, columns and lines used in the demonstration: If the state uses other worksheets, describe them and how they are applied.	This question was removed as no longer relevant given the other questions asked.	No
Section IV. The State applies the Medicaid charge, day, or discharge data as described below to the Medicare charge ratios, per diems, or adjusted DRG amounts:				No
1	Are the Medicaid covered charges/days/discharges from paid claims reported from MMIS?	0 The Medicaid covered charges/days/discharges are from paid claims reported from the MMIS.		No
2	Do the dates of service for the Medicaid charge/day/discharge data [variable 300.1 and variable 300.2] match the dates of services from the Medicare cost report data [variable 200.1 and variable 200.2]?	0 Do the dates of service for the Medicaid charge/day/discharge data match the dates of services from the Medicare cost report data? If no, please explain.		No
	No Question	0 The Medicaid covered charges/days/discharges are from another source. Other source: ¬¬¬¬¬¬_____________.	This question was removed as no longer relevant given the other questions asked.	No
3	Does the state only include Medicaid charges from in-state Medicaid providers?	No change		No
4	Does the charge data exclude crossover claims?	No change		No
5	Are physicians and other professional service charges included?	No change		No
Section V: The UPL demonstration applies Medicaid payment data as follows:
1	Are Medicaid base payment data reported from the MMIS?	Medicaid base payment data is reported from the MMIS. 0 Yes 0 No		No
2	Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period?	If the source of the payment data is a different source, please explain:		No
3	Does the Medicaid payment data include ALL base and supplemental payments to inpatient hospital providers?	Medicaid payment data includes ALL base and supplemental payments to inpatient hospital providers. Note: any reimbursement paid outside of MMIS should also be included (e.g. Organ Acquisition payments, GME payments, etc.). Within the demonstration the base and supplemental payments must be separately identified. 0 Yes 0 No Please explain payments that are made outside of the MMIS.		No
4	Do Medicaid payment data exclude crossover claims?	Medicaid payment data exclude crossover claims. 0 Yes 0 No		No
5	Is the Medicaid payment reported gross or net of the primary payer payments, deductibles, and co-pays?	No change		No
6	Describe how Medicaid payment rates change between the base period and the UPL period are accounted for in the demonstration?	No change		No
6a	Are all adjustments related to approved SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration?	New question	Required to confirm if there are any discrepancies in the adjustsments to Medicaid payments in the periods of the base payments and UPL demonstration period.	No
Section VI: The State trends or adjusts the UPL data, as follows:
1	Does the state trend the UPL for inflation?	The state trends the UPL for inflation 0 Yes 0 No Explain the trending factor and its source.		No
1a	Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience?	No change		No
2	Does the state trend the UPL for volume/utilization?	The state trends the UPL for volume/utilization. 0 Yes 0 No		No
3	Are there any additional trends or factors for the UPL (not for the Medicaid payments) that are used in the UPL demonstration and their application?	Explain the volume/utilization adjustment, including: how will it assure the UPL does not over or understate the volume of Medicaid inpatient hospital services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data: Please explain all additional trends or factors that are used in the demonstration and their application:		No
4	Does the state apply a claims completion factor (when a state does not have a full year of data for the trending factors) to the charge/day/discharge data?	Does the state apply a claims completion factor to the charge/day/discharge data? 0 Yes 0 No		No
5	Does the state apply a claims completion factor to the payment data?	No change		No
5a	If Yes, is the claims completion factor equally applied to the payment and Medicaid charge/day/discharge data used in computing the Medicare UPL (all data in the demonstration should be for a full year)?	Please explain the claims completion factor and its application:		No
Section VII: The state UPL data demonstration is structured as follows:				No
1	Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL demonstration for each applicable provider category (SGO, NSGO, and Private).	All Medicaid base and supplemental payments are included in the demonstration and are separately identified. 0 Yes 0 No		No
2	Does the demonstration include all inpatient hospitals that receive payments under Medicaid?	The state conducted the UPL demonstration separately for state government owned or operated, non-state government owned or operated and privately owned or operated hospitals. 0 Yes 0 No		No
3	Does the UPL demonstration only include in-state hospitals?	The data demonstration only includes in-state hospitals. 0 Yes 0 No If the state includes out of state hospitals in the UPL calculation, please verify that data on cost/payments have been obtained from the cost report of the out of state hospitals and that the hospitals are included in the “private” provider category.		No
4	Are Critical Access Hospitals (CAHs) included?	Are Critical Access Hospitals (CAHs) included? 0 Yes 0 No Describe how the state accounts for CAHs in the UPL calculation? If CAHS are excluded, please explain the decision to exclude them from the UPL and the basis for demonstrating compliance with 42 CFR 447.272.		No
5	Are provider taxes included and/or adjusted for in the UPL data (variable 401)?	New Question	Provider tax information is critical in tracking and calculating of the UPLs	No

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Sheet 2: Outpatient

No.	UPL Outpatient Hospital Guidance Questions in MACFin System	Original Document (PRA completed in January 2021)	Explanation	Burden Change
Section I: UPL Demonstration Overview
1	Are there any significant changes to the prior year UPL methodology?	I. The Basis of the UPL Formula is: 0 Cost-Based Demonstration (e.g. Cost-to-charge ratio X Medicaid covered I/P charges) or 0 Payment-Based Demonstration (e.g. Payment-to-charge ratio X Medicaid covered I/P charges) 0 Medicare DRG (Acuity-Adjusted Price-Based Demonstration)	CMS folded the Old Guidance & Instructions documents into 1 online form that asks questions that before were open text boxes that states had to fill in to explain their methodology. Here the crosswalk includes any changes.	No
2	Does the UPL demonstration align with your state fiscal year?	0 Other (please describe below): Open text box		No
3	Does the UPL demonstration trend data from the previous UPL demonstration submission or does it contain new data? If using trended data, please specify which data variables are trended.	0 Other (please describe below): Open text box		No
4	Does the UPL demonstration include a full 12 months of data for each provider?	Please provide a general description of the formula: Open text box		No
5	Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period?	Please provide a general description of the formula: Open text box		No
6	Has the provider count (providers enrolled in the Medicaid program and included in the UPL demonstration) changed from the previous UPL demonstration?	0 Other (please describe below): Open text box		No
6a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	0 Other (please describe below): Open text box		No
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	0 Other (please describe below): Open text box		No
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for outpatient hospital services.	0 Other (please describe below): Open text box		No
Section II: The source of the UPL Medicare Equivalent Data is:
1	What is the source of the UPL Medicare equivalent data?	II. The source of the UPL Medicare equivalent data is: 0 The Medicare Cost Report (CMS 2552) 0 Filed or 0 Settled or 0 Other Data Source (Please describe)		No
2	What is the time period of the data?	What is the time period of the data? Base year data: ¬________________________ Rate year data: ¬¬¬¬¬¬¬________________________		No
Section III: The State uses the Cost Report References below:
1	Cost-Based Demonstration (Cost-to-Charge Ratio)	Cost-Based Demonstration (Cost-to-Charge Ratio): 0 Worksheet C 0 Worksheet D Describe which columns and lines that are used to determine the cost-to-charge ratios.		No
2	Payment-to-Charge Demonstration (Payment to Charge Ratio)	Payment-to-Charge Demonstration (Payment to Charge Ratio): 0 Worksheet E, Part B (Payments) / Worksheet D, Part V and VI (Charges) Describe which columns and lines that are used to determine the payment-to-charge ratios.		No
3	Does the Medicare payment data represent gross reported payment or are adjustments made to the data to capture the net payment?	No change		No
	No Question	For net reported payments, please explain the adjustments for primary care payments, deductible, coinsurance and reimbursable bad debts. (Please note: if deductibles and coinsurance are added onto the Medicare payment, the state should remove reimbursable bad debts included in the Medicare payments). Other Cost Report Worksheets, Columns and Lines used: If the state uses other worksheets, describe them and how they are applied.	This question was removed as no longer relevant given the other questions asked.	No
Section IV: The State applies the Medicaid charge data, as described below to the Medicare charge ratios:
1	Are the Medicaid covered charges/days from paid claims reported from the MMIS?	The Medicaid charges are from paid claims reported from the MMIS		No
	No Question	The Medicaid charges are from another source. Other source: ¬¬¬¬¬¬_____________.	This question was removed as no longer relevant given the other questions asked.	No
2	Do the dates of service for the Medicaid charge data match the dates of services from the Medicare cost report data?	No change		No
3	Does the state only include Medicaid charges from in-state Medicaid providers?	No change		No
4	Does the charge data exclude crossover claims?	No change		No
5	Are physicians and other professional services excluded?	No change		No
Section V: The UPL demonstration applies Medicaid payment data as follows:
1	Are Medicaid base payment data reported from the MMIS?	Medicaid base payment data is reported from the MMIS. 0 Yes 0 No If the source of the payment data is a different source, please explain:		No
2	Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period?	Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period? 0 Yes 0 No If no, please explain:		No
3	Does the Medicaid payment data include ALL base and supplemental payments to outpatient hospital providers?	Medicaid payment data includes ALL base and supplemental payments to outpatient hospital providers. Base and supplemental payments must be separately identified. Note: any reimbursement paid outside of the MMIS should be included. 0 Yes 0 No Please explain payments that are made outside of the MMIS.		No
4	Do Medicaid payment data exclude crossover claims?	Medicaid payment data exclude crossover claims. 0 Yes 0 No		No
5	Is the Medicaid payment reported gross or net of the primary payer payments, deductibles, and co-pays?	No change		No
6	Describe how Medicaid payment rates change between the base period and the UPL period are accounted for in the demonstration?	No change		No
6a	Are all adjustments related to SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration?	Does the dollar amount of payments for the UPL base period equal the “claimed” amounts on the CMS-64, Medicaid Expenditures report for the UPL time period? 0 Yes 0 No If no, please provide a reconciliation and explanation of the difference?		No
Section VI: The State trends or adjusts the UPL data, as follows:
1	Does the state trend the UPL for inflation?	The State trends the UPL for inflation 0 Yes 0 No Explain the trending factor and its source.		No
1a	Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience?	No change		No
2	Does the state trend the UPL for volume/utilization?	The state trends the UPL for volume/utilization 0 Yes 0 No Explain the volume/utilization adjustment, including: how it will assure the UPL does not over or understate the volume of Medicaid inpatient hospital services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data:		No
3	Are there any additional trends or factors for the UPL (not for the Medicaid payments) that are used in the UPL demonstration and their application?	Please explain all additional trends or factors that are used in the demonstration and their application:		No
4	Does the state apply a claims completion factor (when a state does not have a full year of data for the trending factors) to the charge data?	Please explain the claims completion factor and its application:		No
5	Does the state apply a claims completion factor to the payment data?	no change		No
5a	If Yes, is the claims completion factor equally applied to the payment and Medicaid charge data used in computing the Medicare UPL (all data in the demonstration should be for a full year)?	Is the claims completion factor equally applied to the payment and charge data? 0 Yes 0 No		No
Section VII: The State UPL data demonstration is structured as follows:
1	Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL demonstration for each applicable provider category (SGO, NSGO, and Private).	The state conducted the UPL demonstration separately for state government owned or operated, non-state government owned or operated and privately owned or operated hospitals. 0 Yes 0 No All Medicaid base and supplemental payments are included in the demonstration and are separately identified. 0 Yes 0 No The demonstration includes all facilities that receive outpatient hospital payments under Medicaid. 0 Yes 0 No		No
2	Does the demonstration include all outpatient hospitals that receive payments under Medicaid?	The demonstration includes all facilities that receive outpatient hospital payments under Medicaid. 0 Yes 0 No		No
3	Does the demonstration only include in-state hospitals?	The demonstration only includes in-state hospitals. 0 Yes 0 No		No
4	Are provider taxes included and/or adjusted for in the UPL data (variable 401)?	New Question		No
	No Question	Describe how the state accounts for CAHs in the UPL calculation?	This question was removed as no longer relevant given the other questions asked.	No
	No Question	If CAHS are excluded, please explain the decision to exclude them from the UPL and the basis for demonstrating compliance with 42 CFR 447.321.	This question was removed as no longer relevant given the other questions asked.	No

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Sheet 3: Nursing Facility

No.	UPL Nursing Facility Guidance Questions in MACFin System	Original Document (PRA completed in January 2021)	Explanation	Burden Change
Section I: UPL Demonstration Overview
1	Are there any significant changes to the prior year UPL methodology?	The Basis of the UPL Formula is: 0 Cost-Based Demonstration (e.g. Routine per diem X Medicaid covered days, and Cost-to-charge ratio X Medicaid covered NF charges), or 0 Medicaid Nursing Facility Cost Report Demonstration, or 0 Medicare Resource Utilization Group (RUGs) Payment Demonstration
2	Does the UPL demonstration align with your state fiscal year?	0 Other (please describe below):
3	Does the UPL demonstration trend data from the previous UPL demonstration submission or does it contain new data?	Please provide a general description of the formula:
4	Does the UPL demonstration include a full 12 months of data for each provider?	What is the time period of the data? Base year data: _________________________ Rate year data: _________________________
5	Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period?	Is the data the most recently available to the state? 0 Yes 0 No
6	Has the provider count changed from the previous UPL demonstration?	0 Other (please describe below): Open text box
6a	Please explain the changes, including any new providers, closed providers, or mergers.	0 Other (please describe below): Open text box
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	0 Other (please describe below): Open text box
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for nursing facility services.	0 Other (please describe below): Open text box
Section II: The Source of the UPL Medicare equivalent data is:
1	What is the source of the UPL Medicare Equivalent Data?	II. The source of the UPL Medicare equivalent data is: 0 The Medicare Cost Report (CMS 2540 and 2552 for hospital-based NF services) 0 Filed 0 Settled 0 State Nursing Facility Cost Report 0 Filed 0 Settled 0 Medicare Resource Utilization Group (RUGs) 0 Other Data Source (Please describe)
2	What is the time period of the data?	What is the time period of the data? Base year data: _________________________ Rate year data: _________________________
3	Is the data the most recently available to the state?	Is the data the most recently available to the state? 0 Yes 0 No
Section III: Cost-Based Demonstration using State Developed Nursing Facility Cost Report
1	Please describe the cost report and provide a cross walk of the worksheets, columns, and lines to the equivalent worksheets, columns, and lines reported on the Medicare 2540 or 2552. Please fully detail any variation between the state's cost report and the Medicare cost report.	Cost-Based Demonstration: CMS 2552: 0 Worksheet B (costs) 0 Worksheet C (cost and charges) 0 Worksheet D-1 (per diems) CMS 2540: 0 Worksheet B (costs) 0 Worksheet C (ancillary cost and ancillary charges) 0 Worksheet D-1 (per diems) Describe which columns and lines that are used to determine the cost-to-charge ratios and the routine per diem amounts used in the cost-based UPL. Other Cost Report Worksheets, Columns and Lines used: If the state uses other worksheets, describe them and how they are applied.
2	Please describe the state calculation for Medicare-equivalent cost per diem for each facility.	The State calculates Medicare routine cost per diem for each facility: Describe the calculation:
	No Question	0 The ancillary and routine Medicare costs are determined per facility. The state makes necessary adjustments to account for differences in Medicare and Medicaid costs and charges (e.g. reduces Medicare cost and charges for drugs). 0 Yes 0 No Explain the adjustments?	This question was removed as no longer relevant given the other questions asked.
	No Question	The State applies Medicaid ancillary charge data, as described below to the Medicare ancillary charge ratios: 0 The Medicaid covered charges are from paid claims reported from the MMIS. 0 The Medicaid covered charges are from another source. Other source and description: Do the dates of service for the Medicaid ancillary charge data match the dates of services from the Medicare cost report data? If no, please explain.	This question was removed as no longer relevant given the other questions asked.
	No Question	Does the state only include Medicaid charges from in-state Medicaid residents? 0 Yes 0 No Does the charge data exclude crossover claims? 0 Yes 0 No Are physicians and other professional service charges excluded? 0 Yes 0 No Please explain the inclusion of any professional service charges and verify that those services as covered, billed and paid as Medicaid nursing facility service payments in accordance with the State’s approved State plan methodology.	This question was removed as no longer relevant given the other questions asked.
	No Question	The source of Medicaid covered days are from paid claims reported from the MMIS.	This question was removed as no longer relevant given the other questions asked.
3	Please describe the treatment of capital expenditures.	Describe the treatment of capital expenditures
4	What is the source of the Medicaid covered days?	The source of the Medicaid covered days are the worksheets, columns and lines listed below from a state nursing facility cost report:
Section IV: Medicare Resource Utilization Group (RUGs)
1	Describe the version of the RUGs case-mixed classification system used in the demonstration and the calculation of the Medicare equivalent payment.	Describe the version of the RUGs case-mixed classification system used in the demonstration and the calculation of the Medicare equivalent payment:
2	Describe all adjustments the state makes to account for variation between the Medicare RUGs system and the state's Medicaid nursing facility reimbursement policy.	Describe all adjustments the state makes to account for variation between the Medicare RUGs system and the state’s Medicaid nursing facility reimbursement policy:
Section V: The UPL demonstration applies Medicaid payment data as follows:
1	Are Medicaid base payment data reported from the MMIS?	Medicaid base payment data is reported from the MMIS. 0 Yes 0 No If the source of the payment data is a different source, please explain:
2	Does the Medicaid payment data includes ALL base and supplemental payments to nursing facility providers?	Medicaid payment data includes ALL base and supplemental payments to nursing facility providers. Base and supplemental payments must be identified separately. Note: any reimbursement paid outside of MMIS should also be included (e.g. quality incentive payments.) 0 Yes 0 No Please explain payments that are made outside of the MMIS.
3	Do Medicaid payment data exclude crossover claims?	Medicaid payment data exclude crossover claims. 0 Yes 0 No
4	Is the Medicaid payment reported gross or net of deductibles and co-pays?	Is the Medicaid payment reported gross or net of deductibles and co-pays? 0 Gross 0 Net
5	Describe how Medicaid payment rate changes between the base period and the UPL period are accounted for in the demonstration.	No change
5a	Are all adjustments related to SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration?	Does the dollar amount of payments for the UPL base period equal the “claimed” amounts on the CMS-64, Medicaid Expenditures report for the UPL time period? 0 Yes 0 No If no, please provide a reconciliation and explanation of the difference?
Section VI: The State trends or adjusts the UPL data, as follows:
1	Does the state trend the UPL for inflation?	The State trends the UPL for inflation. 0 Yes 0 No Explain the trending factor and its source.
2	Does the state trend using the RUGs frequency distribution for each facility?	The state trends using the RUGs frequency distribution for each facility: 0 Yes 0 No Please describe the application of the frequency distribution.
3	Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience?	No change
4	Does the state trend the UPL for volume/utilization?	The state trends the UPL for volume/utilization. 0 Yes 0 No Explain the volume/utilization adjustment, including: how it will assure the UPL does not over or understate the volume of Medicaid nursing facility services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data:
5	Does the state apply a claims completion factor to the payment data?	Does the state apply a claims completion factor to the payment data? 0 Yes 0 No Please explain the claims completion factor and its application:
6	Does the state apply a claims completion factor to the day/charge data?	Does the state apply a claims completion factor to the payment data? 0 Yes 0 No Please explain the claims completion factor and its application:
7	Is the claims completion factor equally applied to the payment and day/charge data?	No change
Section VII: The State UPL data demonstration is structured as follows:
1	Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL demonstration for each applicable provider category (SGO, NSGO, and Private).	The state conducted the UPL data demonstration separately for state government owned or operated, non-state government owned operated and privately owned or operated nursing facilities? 0 Yes 0 No All Medicaid base and supplemental payments are included in the demonstration and are separately identified. 0 Yes 0 No
2	Does the demonstration include all nursing facilities that receive payments under Medicaid?	No change
3	Does the data demonstration only include in-state nursing facilities?	The data demonstration only includes in-state nursing facilities. 0 Yes 0 No
4	Are provider taxes included and/or adjusted for in the UPL data (variable 401)?	If the state includes out of state nursing facilities in the UPL calculation, please verify that data on cost/payments have been obtained from the cost report of the out of state nursing and that the nursing facilities are included in the “private” provider category. 0 Yes 0 No