CMS-10398 #13 Guidance Questions: Nursing

UPL Guidance Question (UPDATED)
No.
Section I: UPL Demonstration Overview
1 Are there any significant changes to the prior year UPL methodology?

2

Does the UPL demonstration align with your state fiscal year?

Response or Follow-Up Questions (UPDATED)
Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please explain.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
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3

Does the UPL demonstration trend data from the previous UPL demonstration
submission or does it contain new data?

4

Does the UPL demonstration include a full 12 months of data for each provider?

5

6

6a
6b

Is the beginning date of the data more than 2 years from the beginning date of the
UPL demonstration period?

Add the following note:
Note: The UPL demonstration period should start the day after the previous UPL demonstration period’s end date.
Insert the following options:
Data trended from previous submission
Add the following note:
Note: If using data trended from a previous submission the beginning date of that data must be no more than 2 years from
the beginning date of the current UPL demonstration.
New data
Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
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Insert the following options:
Yes
No

If 'Yes' is selected, insert the following question:
If Yes, please explain.
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Has the provider count changed from the previous UPL demonstration?
Insert the following options:
Yes
No
Please explain the changes, including any new providers, closed providers, or mergers. Insert Text Box

Please list any changes in the provider category designations (SGO, NSGO, and
Private).
7 Indicate the percentage of managed care and FFS in the state’s Medicaid program
overall and also for nursing facility services.
Section II: The Source of the UPL Medicare equivalent data is:
1 What is the source of the UPL Medicare Equivalent Data?

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Note: Insert one of the below text for "Filed" and "Settled" as it applies.
The data from the Medicare Cost reports are Filed and Settled. (If both “Filed and Settled” are shown in the data)
The data from the Medicare Cost reports are Filed. (If only "Filed" is shown in the data)
The data from the Medicare Cost reports are Settled. (If only "Settled" is shown in the data)
Insert the following options: User can choose more than one option.
The Medicare Cost Report (CMS 2540 and 2552 for hospital-based NF services)
If Medicare Cost Report (CMS 2540 and 2552) is selected, Navigate the user to the below Sub header: Sections III and IV
should not be available to the user.
State Developed Nursing Facility Cost Report
If State Developed Nursing Facility Cost Report is selected, then Section IV should not be available to the user.
Medicare Resource Utilization Group (RUGs)
If Medicare Resource Utilization Group (RUGs) is slected, then Section III should not be available to the user.
Patient Driven Payment Method (PDPM)
When 'The Medicare Cost Report' is selected, insert the following:
Sub Header: The State Uses the Medicare Cost Report to Calculate the Medicare Equivalent: Cost-Based Demonstration
using Medicare Cost Report
1. Please select the worksheet(s) that apply. (More than one option can be selected)
Insert the following options to select:
Total All-Payer Cost (SNF Routine Cost):
When this option is chosen please make the following note available: "In the NF Cost Template, cost per diem is used to
calculate the UPL from the cost report period. Where total all-payer SNF routine cost is used, it is divided by the total all-

2

What is the time period of the data?

This will be Read-only for the user.

Note:
Base year data means the 12 month period (this is a date range input) for which the
state has Medicaid and Medicare data that serves as the baseline for the UPL
demonstration.

Base Year Data:

Rate year data means the 12 month period (this is a date range input) for which the
UPL demonstration is being performed. The rate year should be the current UPL
demonstration year.

3

Is the data the most recently available to the state?

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.
2 Please describe the state calculation for Medicare-equivalent cost per diem for each
facility.
3 Please describe the treatment of capital expenditures.
4 What is the source of the Medicaid covered days?

MCR Begin Date: System populated field in variable 200.1
MCR End Date: System populated field in variable 200.2
MCD Begin Date: System populated field in variable 300.1
MCD End Date: System populated field in variable 300.2
Rate Year Data:
State Demonstration Rate Year: System populated field in SFY
Demo Begin Date: System populated field in variable 002
Demo End Date: System populated field in variable 003
Insert the following options:
Yes
No
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Insert the following options:
Paid claims reported from the MMIS
State nursing facility cost report
If 'State nursing facility cost report' is selected, insert the following question:
Please identify the worksheets, columns, and lines from the state nursing facility cost report.
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Section IV: Medicare Resource Utilization Group (RUGs)
1 Describe the version of the RUGs case-mixed classification system used in the
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demonstration and the calculation of the Medicare equivalent payment.
2 Describe all adjustments the state makes to account for variation between the
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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?

2

3

Does the Medicaid payment data includes ALL base and supplemental payments to
nursing facility providers?

Do Medicaid payment data exclude crossover claims?

4

Is the Medicaid payment reported gross or net of deductibles and co-pays?

5

Describe how Medicaid payment rate changes between the base period and the UPL
period are accounted for in the demonstration.
Note:
For example, a SPA is approved between the base period data and the UPL
demonstration period and it increased Medicaid payment rates. The state needs to
account for the payment rate change because it is not represented in the base period
data.
Instructions: In order to account for rate increases or decreases through the approval
of a state plan amendment(s), a state will use variable 308 (Medicaid Inflation Factor),
309 (Other Adjustment to MCD Payments), or 408 (Adjustment to the UPL Gap) in the
OMB-Approved Template. If the rate increase (or decrease) was implemented as a
percentage of the prevailing rate at the time then the state should capture that
percentage in either variable 308 or 309. The state has the option to include the
increase or decrease in variable 308 along with an inflationary increase the state used
to demonstrate the UPL or may include it in variable 309 apart from any inflationary
increase. As well, if the rate increase or decrease was not implemented as a
percentage change but as a specified amount for each provider then the state may
show this in the OMB-Approved Template as specific amounts distributed across all
facilities as appropriate in variable 408.

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain the source of the payment data.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain the source of any payment that are made outside of the MMIS.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If crossover claims are included, please provide an explanation of how they are treated in the UPL.
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Insert the following options:
Gross
Net
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5a

Are all adjustments related to SPAs between the Medicaid data base period and UPL
demonstration period accounted for in the demonstration?

Section VI: The State trends or adjusts the UPL data, as follows:
1 Does the state trend the UPL for inflation?

2

3

4

5

6

7

Does the state trend using the RUGs frequency distribution for each facility?

Is the inflation factor trend applied from mid-point to mid-point in order to most
accurately project future experience?

Does the state trend the UPL for volume/utilization?

Does the state apply a claims completion factor to the payment data?

Does the state apply a claims completion factor to the day/charge data?

Is the claims completion factor equally applied to the payment and day/charge data?

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
Please list each SPA number with a brief description of the adjustment.
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Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please explain the inflation factor and its source (variable 404- description).
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Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
Please describe the application of the frequency distribution.
Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
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Insert the following options:
Yes
No
If 'Yes, is selected, insert the following question:
If Yes, please 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?
Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data.
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Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please explain the claims completion factor and its application.
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Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please explain the claims completion factor and its application.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain the claims completion factor and its application.
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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 Please explain:
demonstration for each applicable provider category (SGO, NSGO, and Private).
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2

3

4

Does the demonstration include all nursing facilities that receive payments under
Medicaid?

Does the data demonstration only include in-state nursing facilities?

Are provider taxes included and/or adjusted for in the UPL data (variable 401)?

Insert the following options:
Yes
No
If "No" is selected, insert the following question:
If No, please explain which nursing facilities that received payments from Medicaid are not included and why.
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Insert the following options:
Yes
No
If "No" is selected, insert the following question:
If No, the nursing facilities should be included in the "private" provider category. The state should also verify that
cost/payment data is obtained from the cost report of the out-of-state nursing facility.
Out-of-state nursing facilities are included in the "private" provider category.
Cost and payment data is obtained from the cost report of the out-of-state nursing facility.
Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please provide an explanation of their inclusion and/or adjustment.
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