CMS-10398 #24 Guidance Questions_Master File_IMD

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.

4

5

6

Note: Trended data may only include variable 223 (Per Diem Charge, Cost, or
Payment).
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 (providers enrolled in the Medicaid program and included in
the UPL demonstration) 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
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, insert 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.
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6b 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
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overall and also for IMD services.
Section II: The source of the UPL Medicare Equivalent Data is:
1 What source is used to obtain the Medicare Equivalent data?
Insert the following options:
Cost Reports, check all that apply:
The Medicare Hospital Cost Report (CMS 2552-10)
The Medicare Skilled Nursing Facility Cost Report (CMS 2540-10)
State Developed Cost Report utilizing Medicare Cost Principles from 45 CFR 75
Other

1a

If Other, please fully explain the date source(s) and how the data is used.

1b

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

If user selects "Other" then add questions 1a and 1b.
Please describe:
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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

2

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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How the price-based demonstration adjusts for differences in Medicare and Medicaid Insert the following options:
patient acuity?
Yes
No
If 'Yes' is selected, insert the following question:
Please explain:
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3

What is the time period of the data?
Note:
The response to this question is auto-generated based on the data in the IMD 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:
1 Indicate which cost report is used and which Worksheets, Parts, Columns, and Lines
are used to populate the data.
2 Does the Medicare payment data represent gross reported payment, or are
adjustments made to the data to capture the net payment?

The below text is Read-only for the user:
Base Year Data:
MCR Begin Date Begin Date for Charge, Cost or Payment Data: System populated field in variable 200.1
MCR End Date End Date for Charge, Cost or Payment Data: System populated field in variable 200.2
MCD Days Begin Date: System populated field in variable 300.1
MCD Days End Date: System populated field in variable 300.2
MCD Rates Begin Date: System populated field in variable 311.1
MCD Rates End Date: System populated field in variable 311.2
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
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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, 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 or day data to the Medicare per diem amounts as described below:
1 Are the Medicaid covered charges and days from paid claims reported from MMIS?
Insert the following options:
Yes
No

2

3

Do the dates of service for the Medicaid charge and day 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]?

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

4

Note: If the state includes Medicaid charges or days from out-of-state, please place
the provider in the private ownership category (Variable 110).
Does the charge data exclude crossover claims?

5

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.
Are physicians and other professional service charges included?

Section V: The UPL demonstration applies Medicaid payment data as follows:
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/day data and the IMD cost reporting period?

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

If No is selected insert the following:
If No, please name the other source.
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Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain why.
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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
IMD service charges and verify that those services are covered, billed, and paid as Medicaid IMD service payments in
accordance with the approved state plan IMD reimbursement methodology.
Insert Text box for this explanation.
Insert the following options:
Yes
No
If 'Yes' 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 IMD service payments in accordance with the approved state plan IMD reimbursement
methodology. If the services are not covered, billed, and paid as Medicaid IMD service payments then the data for these
services should be removed from the IMD 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 crossover claims are included, please provide an explanation of how they are treated in the UPL.
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4

5

6

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 rate changes 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 No, please explain the source of any payments that are made outside of the MMIS.
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Insert the following checkbox:
I confirm that the Medicaid payment data are reported in the same manner as Medicare payment data in "Section III,
question 2" or "Section II, question 1b".
Please describe:
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Note:

6a

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:
and UPL 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?

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 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 '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 IMD 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: Insert Text box

3

4

5

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

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
No
should be for a full year)?
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

Does the demonstration include all IMDs that receive payments under Medicaid?

3

Does the UPL demonstration only include in-state IMDs?

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 IMDs 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 IMD.
Out-of-state IMDs are included in the "private" provider category.
Cost and payment data are obtained from the cost report of the out-of-state IMD.
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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