CMS-10398 #24 Guidance Questions_Master File_ICF IID

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? If using trended data, please specify which
data variables are trended.
Note:
Trended data may only include variable 211 (Medicare Per Diem).

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, 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 ICF/IID services.
Section II: Source of the UPL Medicare Equivalent Data is:
1 What is the basis of the UPL formula?
Insert the following the options:
Medicaid Cost Demonstration Using Medicare Cost Finding Principles
Other
If 'Other' is selected, insert the following question:
If Other, please describe.
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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:
and ending dates?
Base Yeas Data:
MCR Begin Date: System populated field in variable 200.1
Note: The response to this question is auto-generated based on the data in the ICF/IID MCR End Date: System populated field in variable 200.2
MCD Begin Date: System populated field in variable 300.1
UPL submission.
MCD End Date: System populated field in variable 300.2
Base year data means the 12 month period (this is a date range input) for which the
MCD Rates Begin Date: System populated field in variable 311.1
state has Medicaid and Medicare data that serves as the baseline for the UPL
MCD Rates End Date: System populated field in variable 311.2
demonstration.
Rate Year Data:
Rate year data means the 12 month period (this is a date range input) for which the
State Demonstration Rate Year: System populated field in SFY
UPL demonstration is being performed. The rate year should be the current UPL
Demo Begin Date: System populated field in variable 002
demonstration year.
Demo End Date: System populated field in variable 003
3 Is the data the most recently available to the state?
Insert the following options:
Yes
No
Section III. Medicare cost comparison is verified as described below:

1

What is the source of the UPL Medicare equivalent data?

Insert the following options:
State Developed Cost Report using Medicare Cost Identification Principles
Modified Medicare Skilled Nursing Facility Cost Report (CMS 2540)
When user selects Modified Medicare Skilled Nursing Facility Cost then display Question 5 from Cost Report Development
sub-section.
Insert the following question:
a. If the state uses a modified Medicare SNF report, does the state capture the same types of allowable costs as reported
on the Medicare SNF cost report?
Insert the following options:
Yes
No
If 'No' is selected, proceed to questions a1 and a2.
a1. Has the state documented and explained the cost category discrepancies?
Insert the following options:
Yes
No

Cost Report Development (Sub-section)
1 Does the cost report recognize allowable and non-allowable costs in accordance with
Medicare Cost Principles in 42 CFR 413 and 45 CFR 75?

2

3

4

a2. Please explain all discrepancies and modifications to the SNF cost report.
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Insert the following options:
Yes
No

If "No" is selected, insert the following question:
If No, please explain the treatment and allocation of costs. The state will need to discuss with CMS whether this
methodology is acceptable.
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Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report? Insert the following options:
Yes
No

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?

If "No" is selected, insert the following note:
CMS may request that the state submit the cost report for review prior to any acceptance of the submitted UPL
demonstration.

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please describe.
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Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, what is the frequency of the audit?
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Cost Finding Methodology (Sub-section)
1 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). If the cost identification and allocation process
are different from Medicare Cost Principles then please explain.
2 Are indirect/overhead costs and direct service costs separately identified on the cost Insert the following options:
report?
Yes
No
3 Are both routine and ancillary service costs identified on the cost report?
Insert the following options:
Yes
No
4 Are ancillary service costs separately identified on the cost report?
Insert the following options:
Yes
No
4a Please describe how the routine and ancillary costs are reported in the cost report and Insert Text Box
how they are treated for the purpose of determining Medicaid ICF/IID cost.
5 Are Central Office or related entity costs allocated to the ICF/IIDs?
Insert the following options:
Yes
No
There are no Central Office or related entity costs.
If 'Yes' or 'No' is selected, proceed to question 5a.
Please describe how Central Office or related entity costs are identified in the cost
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report and are allocated to represent actual Medicaid incurred cost.
Application of Medicaid days to per diem cost (applies to both state-developed cost report and Medicare-based cost report) (Sub-section)
1 Does the cost report arrive at an ICF/IID cost per diem for each facility and apply
Insert the following options:
Medicaid days to the per diem?
Yes
No
2 For the determination of cost used for the per diem, is cost exclusive or inclusive of
Insert the following options:
cost associated with non-certified beds?
Exclusive
Inclusive
5a

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Have the per diem cost and/or Medicaid rates been adjusted for low occupancy?

4

Is the per diem ICF/IID cost inclusive of all routine and ancillary services?

5

Does the state use paid claims data from the MMIS as the source of the Medicaid
days?

6

Are the Medicaid days used in the UPL calculation from the same period as the cost
report period?

Section IV. Source of the Medicaid Payment Data
1 Are Medicaid base payment data reported from the MMIS?

2

3

4

4a

5

6

7

7a

Does the Medicaid payment data include ALL base and supplemental payments to
ICF/IID providers?

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

Where the state makes Medicaid payment outside of Attachment 4.19-D for other
services furnished to ICF/IID residents, are these Medicaid payments excluded from
the UPL demonstration?
If applicable, please explain any excluded Medicaid payments that are made outside
of 4.19-D. Also please explain how their related costs are excluded from the
computation of the cost UPL.
Note: If not applicable, then indicate "N/A" in the response.
Does the 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 primary payer payments,
deductibles, and co-pays?
Describe how Medicaid payment rate changes between the base period and the UPL
period are accounted for in the demonstration.

Insert the following options:
Yes
No
Insert the following options:
Yes
No
Insert the following options:
Yes
No
Insert the following options:
Yes
No
If 'No' is selected insert the following question:
If No, please explain why they are different.
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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 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 No, please explain.
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Insert the following options:
Yes
No
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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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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.
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 V. The state trends and adjusts the UPL Data, as below:

If 'No' is selected, insert the following question:
Please list each SPA number with a brief description of the adjustment.
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Does the state trend the UPL for inflation?

1a

Does the state exclude capital costs from the trending?

1b

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

2

3

4

5

5a

Does the state trend the UPL for volume/utilization?

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
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 ICF/IID 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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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 or day data?

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

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

If 'Yes' is selected, proceed to question 5a.
If Yes, is the claims completion factor equally applied to the payment and Medicaid
Insert the following options:
charge or day data used in computing the Medicare UPL (all data in the demonstration Yes
should be for a full year)?
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 VI. 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

Does the demonstration include all ICF/IID facilities that receive payments under
Medicaid?

3

Does the demonstration only includes in-state ICF/IIDs?

4

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

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