CMS-10398 #24 Guidance Questions_Master File_PRTF

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 only include variable 223 (Per Diem Charge, Cost, or Payment).

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 (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
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Add the following 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, proceeds 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 PRTF services.
Section II: Basis of the UPL Demonstration
1 What is the basis of the UPL formula?
Insert the following options:
Payment at the provider’s customary charge compared to Medicaid payment
Payment is made at the customary charge level and limited to the prevailing charge in the locality for comparable services
under comparable circumstances
2 Please provide a general description of the formula.
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3 What is the time period of the data?
The below text is Read-only for the user:
Note:
The response to this question is auto-generated based on the data in the PRTF 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.

4

Is the data the most recently available to the state?

Section III: The source of the provider's customary charge data is:
1 Does the state use claims data from the MMIS to determine customary charges for
equivalent Medicaid services?

Base Year Data:
Begin Date for Charge, Cost or Payment Data: System populated field in variable 200.1
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
Insert the following options:
Yes
No
Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please describe the other source(s).
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2

3

Are the providers' charges uniform for all payers?

Describe how the data reflects or is adjusted to account for locality.

Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain how the state calculated the providers' customary charges and the source of the data that is used in
the calculation.
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Insert the following options:
Yes
No

If 'No' is selected, insert the following question:
If No, please explain the differences.
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Section IV: The prevailing charge in the locality for comparable services under comparable circumstances:
1 Was the prevailing charge data for this provider available to the state Medicaid
Insert the following options:
agency?
Yes
No
2 Do the prevailing charge data used in the calculation come from claims data from the Insert the following options:
Yes
MMIS?
No

3
4
5

If 'No' is selected, insert the following question:
If No, please describe the other source(s) and the basis for determining prevailing charges.
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Describe how the data reflects or is adjusted to account for locality.
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Describe how the data reflects or is adjusted to represent comparable services under Insert text box
comparable circumstances.
Does the demonstration use prevailing charges for the same services that are paid
Insert the following options:
Yes
under the Medicaid program?
No

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

Does the Medicaid payment data include ALL base and supplemental payments to
PRTF 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 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.

If 'No' is selected, insert the following question:
If No, please explain the differences.
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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 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:
Gross
Net
Insert the following:
Please describe.
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5a

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 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) and why it is an applicable inflation to the
customary and/or prevailing charges.
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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 PRTF services provided in the rate year?
How it is applied?
Discuss how it is applied consistently to the Medicare equivalent (200-level series variables in the template) and Medicaid
payment data.
Please explain:
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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 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 VII: The state UPL data demonstration is structured as follows:
1 Did the state conduct the UPL demonstration individually for each facility?

2

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:
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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Insert the following options:
Yes
No

If "No" is selected, insert the following question:
If No, please explain.
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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.

3

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

Insert the following options:
Yes
No
If "No" is selected, insert the following question:
If No, please explain which PRTFs that received payments from Medicaid are not included and why.
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4

Does the data demonstration only include in-state PRTFs?

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