CMS-10398 #13 Guidance Questions: Outpatient

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

4

5

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.
Note:
Trended data may include variables 203 (Medicare Costs), 204 (Medicaid Charges),
and 205 (Medicare Payments).
Does the UPL demonstration include a full 12 months of data for each provider?

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

Add the following 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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6 Has the provider count (providers enrolled in the Medicaid program and included in
Insert the following options:
Yes
the UPL demonstration) changed from the previous UPL demonstration?
No
6a Please explain the changes, including any new providers, closed providers, or mergers. Insert Text Box
Please also cite the source of this data.
6b Please list any changes in the provider category designations (SGO, NSGO, and
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Private).
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7 Indicate the percentage of managed care and FFS in the state’s Medicaid program
overall and also for outpatient hospital services.
Section II: The source of the UPL Medicare Equivalent Data is:
1 What is the source of the UPL Medicare equivalent data?
Insert the following options:
Medicare Cost Report (CMS 2552)
Other Data Source
If 'Medicare Cost Report (CMS 2552)' is selected, insert the following question and options.
*Note that both Filed and Settled may be selected.*
The Medicare Cost Report (CMS 2552) is:
Filed (System populated field in Variable 202 from spreadsheet - Read only)
Settled (System populated field in Variable 202 from spreadsheet - Read only)
If both “Filed and Settled” are shown in the data, the following text shall display:
The data from the Medicare Cost reports are Filed and Settled.
If only "Filed" is shown in the data, the following text shall display:
The data from the Medicare Cost reports are Filed.
If only "Settled" is shown in the data, the following text shall display:
The data from the Medicare Cost reports are Settled.

2

What is the time period of the data?
Note: The response to this question is auto-generated based on the data in the OPH
UPL submission.
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.

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.
Section III: The State uses the Cost Report References below:

If 'Other Data Source' is selected, insert the following question:
If the UPL Medicare equivalent data is from a different source, please describe.
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The following Base Year Data and Rate Year Data should display as read-only:
Base Year Data:
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

1

Cost-Based Demonstration (Cost-to-Charge Ratio)

Insert the following options:
Worksheet C
Worksheet D
If Worksheet C is selected, insert the following options:
*Note the user should be able to select both options.
Medicare Cost Variable 203
Medicare Charges Variable 204
If Medicare Cost Variable 203 is selected then insert
WKST C, Part 1, Column 5, Sum of lines 50-98
If Medicare Charges Variable 204 is selected, insert the following options:
WKST C, Part 1, Column 7, Sum of lines 50-98, or
WKST D, Part V, Columns 2-4, Sum of lines 50-98
If both Medicare Charges Variable 203 and Variable 204 are selected, all worksheets shall be displayed to the user under
each option.

2

Payment-to-Charge Demonstration (Payment to Charge Ratio)

If Worksheet D is selected, insert the following information:
Describe which columns and lines that are used to determine the cost-to-charge ratios.
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Insert the following option:
Worksheet E, Part B
Other
If Worksheet E, Part B is selected, insert the following options:
*Note the user should be able to select both options.
Medicare Payments Variable 205
Medicare Charges Variable 204
If Medicare Payments variable 205 is selected then insert:
For Medicare OPPS Gross Payments - WKST E, Part B, Sum of lines 21 and 24
For Medicare OPPS Net Payments - WKST E, Part B, Sum of lines 21, 24, 33, and 35 minus lines 25, 26, and 31.
If Medicare Charges variable 204 is selected then insert:
WKST C, Part 1, Column 7, Sum of lines 50-98, or
WKST D, Part V, Columns 2-4, Sum of lines 50-98
If both Medicare Charges Variable 205 and Variable 204 are selected, all worksheets shall be displayed to the user under
each option.

3

Does the Medicare payment data represent gross reported payment or are
adjustments made to the data to capture the net payment?

If no worksheet is selected, insert the following question:
If you are not utilizing the listed worksheets, please describe which worksheets, columns, and lines are used.
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Insert the following options:
Note: The selection for this question must match the selection in "Section V", question 5
Gross
Net

If Net is selected, insert the following:
If Net, please explain the adjustments for primary payer 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).
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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?
Insert the following options:
Yes
No

2

If No is selected, insert the following question:
Please name the other source.
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Do the dates of service for the Medicaid charge data match the dates of services from Insert the following options:
the Medicare cost report data?
Yes
No

3

Does the state only include Medicaid charges from in-state Medicaid providers?

4

Note: If the state includes Medicaid charges from out-of-state, please place the
provider in the private ownership category. (Variable 110)
Does the charge data exclude crossover claims?
Note: Crossover claims are claims that are both Medicare and Medicaid and are for
dual eligible beneficiaries. These claims should be excluded for UPL demonstration
purposes because Medicaid only pays the deductible/coinsurance or copay amount of
the claim or the difference between the Medicaid and Medicare payment rate if the
Medicaid rate is higher. The Medicaid portion of the claim would be much lower as a
payer on the claim and would not represent the normal Medicaid payment. As such,
the UPL gap would not reflect the true gap.

If 'No' is selected, insert the following question:
If No, please explain.
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Insert the following options:
Yes
No
Insert the following options:
Yes
No
If 'No' is selected, insert the following:
Explain how including the crossovers would provide a more relevant estimate. If included, please explain the inclusion of all
outpatient hospital service charges and verify that those services are covered, billed, and paid as Medicaid outpatient
hospital service payments in accordance with the approved state plan outpatient hospital reimbursement methodology.
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5

Are physicians and other professional services excluded?

Section V: The UPL demonstration applies Medicaid payment data as follows:
1 Are Medicaid base payment data reported from the MMIS?

2

3

4

5

6

Are the dates of service for the Medicaid payment data consistent with the Medicaid
charge data and the hospital cost reporting period?

Does the Medicaid payment data include ALL base and supplemental payments to
outpatient hospital providers?

Do Medicaid payment data exclude crossover claims?
Note:
Crossover claims are claims that are both Medicare and Medicaid and are for dual
eligible beneficiaries. These claims should be excluded for UPL demonstration
purposes because Medicaid only pays the deductible/coinsurance or copay amount of
the claim or the difference between the Medicaid and Medicare payment rate if the
Medicaid rate is higher. The Medicaid portion of the claim would be much lower as a
payer on the claim and would not represent the normal Medicaid payment. As such,
the UPL gap would not reflect the true gap.
Is the Medicaid payment reported gross or net of the primary payer payments,
deductibles, and co-pays?
Describe how Medicaid payment rates change between the base period and the UPL
period are accounted for in the demonstration?

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If included, please explain the inclusion of any professional service charges and verify that those services are covered,
billed, and paid as Medicaid Outpatient Hospital service payments in accordance with the State's approved state plan
methodology. If the services are not covered, billed, and paid as Medicaid Outpatient Hospital service payments then the
data for these services should be removed from the OPH UPL demonstration.
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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 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.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain payments 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:
I acknowledge the response for this question has been selected in "Section III", question 3.The value from Section III,
question 3 will be inserted.
Please describe:
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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.

6a

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.
Are all adjustments related to SPAs between the Medicaid data base period and UPL Insert the following options:
demonstration period accounted for in the demonstration?
Yes
No

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

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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1a

2

3

4

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?

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
Insert Text box
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 outpatient hospital services provided in the
rate year?
How it is applied?
Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data.
Please explain:
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Are there any additional trends or factors for the UPL (not for the Medicaid payments) Insert the following options:
Yes
that are used in the UPL demonstration and their application?
No

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?

5

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

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)?

If 'Yes' is selected, insert the following question:
If Yes, please explain all additional trends or factors for the UPL.
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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
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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Note: If there were no significant increase or decrease in the UPL Gap from the
previous year, then insert "No significant increase or decrease from the previous year"
as the response.
2

3

4

Does the demonstration include all outpatient hospitals that receive payments under Insert the following options:
Medicaid?
Yes
No
Does the demonstration only include in-state hospitals?
Insert the following options:
Yes
No

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

If "No" is selected, insert the following question:
If No, the hospitals should be included in the "private" provider category. The state should also verify that cost/payment
data are obtained from the cost reports of the out-of-state hospitals.
Out-of-State hospitals are included in the "private" provider category.
Cost and payment data are obtained from the cost reports of the Out-of-State hospitals.
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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