CMS-10398 #24 Guidance Questions_Master File_Clinic

UPL Guidance Question
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
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? 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).

4

5

6

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?

Has the provider count changed from the previous UPL demonstration?

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
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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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Insert the following options:
Yes
No

If 'Yes' is selected, proceed to questions 6a and 6b.
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).
7 Indicate the percentage of managed care and FFS in the state’s Medicaid program
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overall and also for Clinic services.
Section II: Description of Clinic services included
1 Does this demonstration apply to all Medicaid freestanding clinics?
Insert the following options:
Yes
No
1a Please describe the Medicaid freestanding clinic type(s).
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State clinic service payment methodology for the services: (Sub-section)
1 Does the state pay a Medicaid fee schedule rates for all services provided by the
Insert the following options:
clinic?
Yes
No
2 Does the state pay clinics a fee schedule amount per CPT billing code using a
Insert the following options:
percentage of the Medicare fee that is currently in effect?
Yes
No

3

3a

Does the state pay clinics using an encounter rate?

If yes, does the state track by CPT or other billing code the individual services that
Medicaid beneficiaries actually receive?

Demonstration comprehensiveness: (Sub-section)

If Yes is selected, insert the following options:
If Yes, state the percentage(s).
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Insert the following options:
Yes
No
If Yes is selected, proceed to question 3A.
Insert the following options:
Yes
No
If No is selected, insert the following options:
If No, please explain.
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Are all of the Medicaid clinic services provided by the providers listed above in Section Insert the following options:
Yes
II question 1a accounted for in the demonstration?
No

Section III: The basis of the UPL formula is:
1 What is the basis of the UPL formula?

If No is selected, insert the following options:
If No, please explain.
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Insert the following options:
State payment rate schedule to Medicare RBRVS Comparison Demonstration (Medicare non-facility fee schedule per CPT)
Medicaid Cost Demonstration

2

What is the time period of the data used in the demonstration, including the beginning The below options and text are Read-only for the user:
Base Year Data:
and ending dates?
UPL Source Begin Date: System populated field in variable 200.1
UPL Source End Date: System populated field in variable 200.2
Note:
MCD Begin Date: System populated field in variable 300.1
The response to this question is auto-generated based on the data in the Clinic UPL
MCD End Date: System populated field in variable 300.2
submission.
Base year data means the 12 month period (this is a date range input) for which the
Rate Year Data:
state has Medicaid and Medicare data that serves as the baseline for the UPL
State Demonstration Rate Year: System populated field in SFY
demonstration.
Demo Begin Date: System populated field in variable 002
Demo End Date: System populated field in variable 003
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?
Insert the following options:
Yes
No
Section IV: Medicare payment comparison is verified as described below:
1 What is the source of the UPL Medicare equivalent data (200-level series variables in Insert the following options:
the template)?
Medicare Fee Schedule
1a Is the Medicare fee schedule for the same time period as the Medicaid payment data? Insert the following options:
Yes
No
1b What is the date of the Medicare fee schedule that is used in the demonstration?
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Identification of Medicare Equivalent Codes: (Sub-section)
1 Are all Medicaid services linked to a Medicare-equivalent CPT code?
Insert the following options:
Yes
No

1a

If the services are not directly comparable to a Medicare payment for a particular
billing code, can the state demonstrate a reasonably equivalent Medicare code to
compare to the Medicaid payment?

2

Does the state apply Medicaid volume of service rendered within the demonstration
period to each CPT code?

3

Is the volume determined based on an analysis of claims data from the MMIS?

If No is selected, insert the following options and proceed to question 1a.
If No, please explain and provide a crosswalk between CPT and local codes.
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Insert the following options:
Yes
No
If Yes is selected, insert the following options:
If Yes, please explain the Medicare codes, or equivalent codes, used in the demonstration and the equivalent Medicaid
payment.
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Insert the following options:
Yes
No
Insert the following options:
Yes
No
If Yes is selected, insert the following option:
If Yes, please describe the analysis.
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Section V: Medicare cost comparison is verified as described below:
1 What is the source of the UPL Medicare equivalent data (200-level series variables in
the template)?

If No is selected, insert the following option:
If No, please describe the analysis.
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Insert the following options:
State Developed Cost Report using Medicare Cost Identification Principles
Modified Medicare Federally Qualified Health Center (FQHC) Cost Report Template (CMS 222)
When user selects option 1 display sub-sections “State Developed Cost Report”, “Direct Cost Finding Methodology”, and
“Charge Ratio Methodology”.

State Developed Cost Report (Sub-section)
1 Does the cost report recognize allowable and non-allowable costs in accordance with
Medicare Reimbursement Principles (PRM-15-1) and 45 CFR 75?
2

When the user selects option 2 display sub-section “Medicare FQHC Cost Report” section.

Insert the following options:
Yes
No
Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report? Insert the following options:
Yes
No

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4

Do providers submit the cost reports to the State Medicaid agency annually?

Is the cost report audited by the state agency or through an independent audit?

Direct Cost Finding Methodology (Sub-section)
1 Does the cost report identify costs directly for Medicaid allowable service cost using
an allocation methodology?
2

Insert the following options:
Yes
No
If No is selected, insert the following options:
If No, please describe the submission period.
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Insert the following options:
Yes
No
If Yes is selected, insert the following options:
If Yes, what is the frequency of the audit?
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Insert the following options:
Yes
No
Please describe the cost identification and allocation process (including the recognized Insert Text Box
direct costs, treatment of indirect cost, all allocation methods used to determine the
costs related to Medicaid services).

Note: You may also satisfy this information request by attaching your cost report and
cost report instruction.
Charge Ratio Methodology (Sub-section)
1 Does the cost report capture all payer cost-to-charge ratios?
Insert the following options:
Yes
No
2 Does the state apply the Medicaid clinic charges to the cost-to-charge ratios from the Insert the following options:
same time period as the cost report data?
Yes
No
3 Are the Medicaid charges reported to the MMIS?
Insert the following options:
Yes
No
4 Please specify the time period of the data used in the state’s cost report.
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Medicare FQHC Cost Report (Sub-section)
1 Does the provider submit FQHC-based cost reports annually to the state?
Insert the following options:
Yes
No

2

3

If No is selected, insert the following options:
If No, what is the reporting period?
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Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report? Insert the following options:
Yes
No
Does the state capture the same types of allowable costs as reported on the Medicare Insert the following options:
FQHC cost report?
Yes
No

4 Please explain all discrepancies and modifications to the FQHC cost report.
5 Please specify the time period of the data used in the FQHC cost report.
Section VI: Source of the Medicaid Payment Data
1 Are Medicaid base payment data reported from the MMIS?

2

3

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

Does the Medicaid payment data include ALL base and supplemental payments to
clinic providers?
Note: Base and supplemental payments must be separately identified. Any
reimbursement paid outside of the MMIS should be included.

4

Do Medicaid payment data exclude crossover claims?

If No is selected, insert the following options:
If No, has the state documented and explained the cost category discrepancies?
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Insert the following options:
Yes
No
If No is selected, insert the following options:
If No, please explain.
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Insert the following options:
Yes
No
If No is selected, insert the following options:
If No, please explain.
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Insert the following options:
Yes
No
If No is selected, insert the following options:
If No, please explain payments that are made outside of the MMIS.
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Insert the following options:
Yes
No

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 If 'No' is selected, insert the following question:
the claim or the difference between the Medicaid and Medicare payment rate if the If crossover claims are included, please provide an explanation of how they are treated in the UPL.
Medicaid rate is higher. The Medicaid portion of the claim would be much lower as a Insert Text Box
payer on the claim and would not represent the normal Medicaid payment. As such,
the UPL gap would not reflect the true gap.

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6

6a

Is the Medicaid payment reported gross or net of primary care payments, deductibles Insert the following options:
Gross
and co-pays?
Net
Describe how Medicaid payment rate changes between the base period and the UPL Insert Text Box
period are accounted for in the demonstration.
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.
Are all adjustments related to approved SPAs between the Medicaid data base period Insert the following options:
Yes
and UPL demonstration period accounted for in the demonstration?
No

Section VII: The state trends and adjusts the UPL Data, as below:
1 Does the state trend the UPL for inflation?

1a

2

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?

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 options:
If Yes, please explain the trending factor and its source (variable 404 - description).
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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 'Yes' is selected, insert the following question:
If Yes, explain the volume/utilization adjustment, including:
How it will assure the UPL does not over or understate the volume of Medicaid clinic 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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3

4

5

5a

Are there any additional trends or factors for the UPL (not for the Medicaid payments) Insert the following options:
that are used in the UPL demonstration and their application?
Yes
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?

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

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)?

Section VIII: The state meets clinic UPL demonstration requirements, as below:

If Yes is selected, insert the following options:
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 options:
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, proceed to question 5a:
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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Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL Please explain:
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demonstration for each applicable provider category (SGO, NSGO, and Private).
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

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

3

Does the demonstration only includes in-state clinics?

Insert the following options:
Yes
No
Insert the following options:
Yes
No
If "No" is selected, insert the following question:
If No, the clinics 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 clinics.
Out-of-state clinics are included in the "private" provider category.
Cost and payment data are obtained from the cost report of the out-of-state clinics.