| Section No. | UPL Guidance Question (ORIGINAL) | Response (ORIGINAL) | No. | UPL Guidance Question (UPDATED) | Response or Follow-Up Questions (UPDATED) |
| Section I. The Basis of the UPL Formula is: | Section I. UPL Demonstration | ||||
| The following check boxes are listed: Cost-Based Demonstration (e.g. Cost-to-charge ratio X Medicaid covered I/P charges) or Payment-Based Demonstration (e.g. Payment-to-charge ratio X Medicaid covered I/P charges) Medicare DRG (Acuity-Adjusted Price-Based Demonstration) Other (please describe below): Text Box |
1 | Are there any significant changes to the prior year UPL methodology? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text Box |
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| Please provide a general description of the formula: | Text Box | 2 | Does the UPL demonstration align with your state fiscal year? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box Add the following note: Note: The UPL demonstration period should start the day after the previous UPL demonstration period’s end date. |
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| Section II. The source of the UPL Medicare Equivalent Data is: | 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), 205 (Medicare Payments), 205.1 (Medicare Payments Subject to CMI), and 205.2 (Medicare Payments not Subject to CMI). |
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 |
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| The following check boxes are listed: The Medicare Cost Report (CMS 2552-96 or 2552-10) Filed Settled Medicare Price-Based Diagnostic Related Group (DRG) |
4 | Does the UPL demonstration include a full 12 months of data for each provider? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text Box |
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| Indicate the year of the grouper: | Text Box | 5 | Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text box |
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| Does the state have separate DRG amounts for state, non-state government, and private providers? |
The following options are listed: Yes No |
6 | Does this UPL demonstration include Institutions for Mental Disease (IMDs)? | Insert the following options: Yes No |
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| Were all claims included in the DRG demonstration or a sample? | The following options are listed: Yes No |
7 | Has the provider count (providers enrolled in the Medicaid program and included in the UPL demonstration) changed from the previous UPL demonstration? | Insert the following options: Yes No |
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| Explain the sample and the basis for using sampling: | Text Box | 7a | Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data. | Insert text box | |
| Describe the application of the DRG: | Text Box | 7b | Please list any changes in the provider category designations (SGO, NSGO, and Private). | Insert text box | |
| Please explain the pricer factors and how they tie to what Medicare has established for the providers in the base year. Also explain how mother and baby days are handled. | Text Box | 8 | Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for inpatient hospital services. | Insert text box | |
| The following check box is listed: The State calculates a per discharge amount per facility |
Section II. The Medicare Equivalent Data | ||||
| Is the per discharge amount run through the Medicare grouper? | The following options are listed: Yes No |
1 | What is the source of the Medicare Equivalent Data (200-level series variables in the template)? | Insert the following options: Note: The values Filed and Settled are from the UPL Demonstration spreadsheet. Note: According to the submitted UPL demonstration the Medicare Cost Report filing status is “Filed”. Note: According to the submitted UPL demonstration the Medicare Cost Report filing status is “Filed and Settled”. Note: According to the submitted UPL demonstration the Medicare Cost Report filing status is “Settled”. The CMS 2552-10 Cost Report Medicare Prospective Payment System (PPS) Diagnostic Related Group (DRG) If user selects DRG then add the following question: Indicate the version of the grouper. Insert text box. System to populate the following: MCR Cost Report Begin Date: System populated field in Variable 200.1 MCR Cost Report End Date: System populated field in Variable 200.2 If user selects DRG then add questions: 1a, 1b, 1c, 1d listed below. |
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| Please detail the calculation of the per discharge amount. | Text Box | 1a | Does the state have separate DRG amounts for state, non-state government, and private ownership categories? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain how you calculated those amounts for each of the different ownership categories. Insert Text Box |
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| Please explain how the price-based demonstration adjusts for differences in Medicare and Medicaid patient acuity. | Text Box | 1b | Describe the methodology for calculating the DRG UPL (variables 205.1, 205.2, 207& 305, as calculated in variable 400 - the unadjusted UPL). | Please describe: Insert text box |
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| Please explain all other data source(s) used in the UPL calculation. | Text Box | 1c | Explain the pricer factors and how they tie to what Medicare has established for the providers in the base year. | Please describe: Insert text box |
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| What is the time period of the data? | Base year data: Text Box Rate year data: Text Box |
1d | Does the State calculate a per discharge amount per facility? (variables 205.1, 205.2, 206, & 207) | Insert the following options: Yes No If 'Yes' is selected, insert the following question: Is the per discharge amount run through the Medicare grouper? Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please detail the calculation of the per discharge amount. Insert Text box |
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| Section III. The State uses the Cost Report References below: | 2 | How does the Medicare PPS demonstration adjusts for differences in Medicare and Medicaid patient acuity? | Please describe: Insert text box |
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| Cost-Based Demonstration (e.g. Ancillary Cost-to-Charge Ratio and Room and Board per Diems): | The following options are listed: Worksheet B Worksheet C Worksheet D-1 |
3 | What are the other data source(s) used in the UPL calculation? Note: If no other data source(s) are used in the UPL calculation, then insert "No other sources were used in the calculation" as the response. |
Please describe: Insert text box |
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| Describe which columns and lines that are used to determine the cost-to-charge ratios and, if applicable, the hospital routine per diem amounts used in the cost-based UPL. | Text Box | 4 | What is the time period of the data? Note: The response to this question is auto-generated based on the data in the IPH 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 to calculate the DRG differential ratio factor. Rate year data means the 12 month period (this is a date range input) for which the DRG differential ratio factor is applied to an estimated Medicaid payment to determine the UPL for the demonstration period. The rate year should be the current UPL demonstration year. |
The below text is Read-only for the user: 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 |
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| Payment-to-Charge Demonstration (Payment to Charge Ratio) use: | The following option is listed: Worksheet E, Part A (Payments) / Worksheet D-4 (Charges) |
Section III. The State uses the Cost Report References below: | |||
| Describe which worksheets, columns and lines that are used to determine the Medicare payments and charges to calculate the payment-to-charge ratio(s). | Text Box | 1 | Cost-Based Demonstration (e.g., Ancillary Cost-to-Charge Ratio and Room and Board Per Diem) | Insert the following options for the user to select: Worksheet C Worksheet B Worksheet D-1 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 30-76 If Medicare Charges Variable 204 is selected, insert the following options: WKST C, Part 1, Column 6, Sum of lines 30-76, or WKST D-3, Column 2, Sum of line 30-98 If both Medicare Charges Variable 203 and Variable 204 are selected, all worksheets shall be displayed to the user under each option. If Worksheet B is selected, insert the following information: Describe which columns and lines that are used to determine the cost-to-charge ratios. Insert text box If Worksheet D-1 is selected, insert the following information: Describe which columns and lines that are used to determine the cost-to-charge ratios. Insert text box |
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| Does the Medicare payment data represent gross reported payment or are adjustments made to the data to capture the net payment? | The folling options are listed: Gross Net |
2 | Payment-to-Charge Demonstration (Payment to Charge Ratio) used (Note: More than one option can be selected) | Insert the following options to select: Medicare Payments Variable 205 (Medicare IPPS payments) – WKST E part A column 1, sum of lines 59 minus lines 68 and 69 Medicare Payments Variable 205 (TEFRA) – WKST E-3 part I column 1 line 4 Medicare Payments Variable 205 (Inpatient Psych Payments) – WKST E-3 part II column 1, sum of lines 16, 27 & 28 minus line 29 Medicare Payments Variable 205 (Inpatient Rehab payments) – WKST E-3 part III column 1, sum of lines 17,28 & 29 minus line 30 Medicare Payments Variable 205 (Long Term Acute Care payments) – WKST E-3 part IV column 1, sum of lines 7,18,19 minus line 20 Medicare payments Variable 205 (Critical Access Hospital Payments) WKST E-3 part V column 1, line 19 minus line 21 Medicare Charges Variable 204 WKST C part 1 column 6, sum of lines 30-76 or WKST D-3 column 2 , sum of lines 30-98. If no worksheets are selected, insert the following question: If you are not utilizing the listed worksheets, please describe which worksheets, columns, and lines are used. Insert Text Box |
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| For net reported payments, 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). | Text Box | 3 | Does the Medicare payment data represent gross reported payment, or are adjustments made to the data to capture the net payment? | Insert the following options: Note: The selection for this question must match the selection in "Section V", question 4. 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). Insert Text box |
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| Please describe all other cost report worksheets, columns and lines used in the demonstration: If the state uses other worksheets, describe them and how they are applied. |
Text Box | Section IV. The State applies the Medicaid charge, day, or discharge data as described below to the Medicare charge ratios, per diems, or adjusted DRG amounts: | |||
| Section IV: The state applies the Medicaid charge, day, or discharge data as described below to the Medicare charge ratios, per diems, or adjusted DRG amounts: | 1 | Are the Medicaid covered charges/days/discharges from paid claims reported from MMIS? | Insert the following options: Yes No If No, please name the other source. Insert text Box |
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| The following check boxes are listed: The Medicaid covered charges/days/discharges are from paid claims reported from the MMIS. The Medicaid covered charges/days/discharges are from another source. Other source: _____________. Do the dates of service for the Medicaid charge/day/discharge data match the dates of services from the Medicare cost report data? If no, please explain. |
2 | Do the dates of service for the Medicaid charge/day/discharge 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]? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain why. Insert Text box |
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| Does the state only include Medicaid charges from in-state Medicaid residents? | The following options are listed Yes No |
3 | Does the state only include Medicaid charges from in-state Medicaid providers? Note: If the state includes Medicaid charges from out-of-state, please place the provider in the private ownership category. (Variable 110) |
Insert the following options: Yes No |
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| Does the charge data exclude crossover claims? | The following options are listed Yes No |
4 | 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. |
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 inpatient hospital service charges and verify that those services are covered, billed, and paid as Medicaid inpatient hospital service payments in accordance with the approved state plan inpatient hospital reimbursement methodology. Insert Text box for this explanation. |
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| Are physicians and other professional service charges excluded? | The following options are listed Yes No |
5 | Are physicians and other professional service charges included? | 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 Inpatient Hospital service payments in accordance with the approved state plan inpatient hospital reimbursement methodology. If the services are not covered, billed, and paid as Medicaid Inpatient Hospital service payments then the data for these services should be removed from the IPH UPL demonstration. Insert Text box |
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| Please explain the inclusion of any professional service charges and verify that those services are covered, billed and paid as Medicaid inpatient hospital service payments in accordance with the approved state plan inpatient hospital reimbursement methodology. | Text Box | Section V: The UPL demonstration applies Medicaid payment data as follows: | |||
| Section V. The UPL demonstration applies Medicaid payment data as follows: | 1 | Are Medicaid base payment data reported from the MMIS? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain the source of the payment data. Insert Text box |
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| Medicaid base payment data is reported from the MMIS. | The following options are listed: Yes No |
2 | Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert text box |
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| If the source of the payment data is a different source, please explain: | Text Box | 3 | Does the Medicaid payment data include ALL base and supplemental payments to inpatient hospital providers? | 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. Insert Text Box |
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| Medicaid payment data includes ALL base and supplemental payments to inpatient hospital providers. Note: any reimbursement paid outside of MMIS should also be included (e.g. Organ Acquisition payments, GME payments, etc.). Within the demonstration the base and supplemental payments must be separately identified. | The following options are listed: Yes No |
4 | 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. |
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. Insert Text Box |
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| Please explain payments that are made outside of the MMIS. | Text Box | 5 | Is the Medicaid payment reported gross or net of the primary payer payments, deductibles, and co-pays? | Insert the following options: I confirm that the Medicaid payment data are reported in the same manner as Medicare payment data in "Section III, question 3. The value from Section III, question 3 will be inserted. |
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| Medicaid payment data exclude crossover claims. | The following options are listed: Yes No |
6 | Describe how Medicaid payment rates change 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. |
Please describe: Insert text box. |
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| Is the Medicaid payment reported gross or net of primary care payments, deductibles and co-pays? | The following options are listed: Gross Net |
6a | Are all adjustments related to approved SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration? | Insert the following options: Yes No N/A If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box |
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| Describe how Medicaid payment rate changes between the base period and the UPL period are accounted for in the demonstration? | Text Box | Section VI: The State trends or adjusts the UPL data, as follows: | |||
| Does the dollar amount of payments for the UPL base period equal the “claimed” amounts on the CMS-64, Medicaid Expenditures report for the UPL time period? | The following options are listed: Yes No |
1 | Does the state trend the UPL for inflation? | 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). Insert Text box |
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| If no, please provide a reconciliation and explanation of the difference? | Text Box | 1a | Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box |
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| Section VI. The State trends or adjusts the UPL data, as follows: | 2 | 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, explain the volume/utilization adjustment, including: How it will assure the UPL does not over or understate the volume of Medicaid nursing facility 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 |
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| The state trends the UPL for inflation | The following options are listed: Yes No |
3 | Are there any additional trends or factors for the UPL (not for the Medicaid payments) that are used in the UPL demonstration and their application? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain all additional trends or factors for the UPL. Insert Text box |
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| Explain the trending factor and its source. | Text Box | 4 | 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/day/discharge data? | 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. Insert text box |
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| Is the inflation trend applied from “mid-point to the mid-point” in order to most accurately project future experience? | The following options are listed: Yes No |
5 | Does the state apply a claims completion factor to the payment data? | Insert the following options: Yes No If 'Yes' is selected, insert question 5a. |
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| The state trends the UPL for volume/utilization. | The following options are listed: Yes No |
5a | If Yes, is the claims completion factor equally applied to the payment and Medicaid charge/day/discharge data used in computing the Medicare UPL (all data in the demonstration should be for a full year)? | 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 Insert Text Box |
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| Explain the volume/utilization adjustment, including: how will it assure the UPL does not over or understate the volume of Medicaid inpatient hospital services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data: | Text Box | Section VII: The state UPL data demonstration is structured as follows: | |||
| Please explain all additional trends or factors that are used in the demonstration and their application: | Text Box | 1 | Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL 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. |
Please explain: Insert text box. |
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| Does the state apply a claims completion factor to the charge/day/discharge data? | The following options are listed: Yes No |
2 | Does the demonstration include all inpatient hospitals that receive payments under Medicaid? | Insert the following options: Yes No |
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| Please explain the claims completion factor and its application: | Text Box | 3 | Does the UPL demonstration only include in-state hospitals? | Insert the following options: Yes No 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. |
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| Does the state apply a claims completion factor to the payment data? | The following options are listed: Yes No |
4 | Are Critical Access Hospitals (CAHs) included? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, describe how the state accounts for CAHs in the UPL calculation (identified in variable 113). Insert Text box If 'No' is selected, insert the following question: If No, please explain the decision to exclude them from the UPL and the basis for demonstrating compliance with 42 CRF 447.272. Insert text Box |
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| Is the claims completion factor equally applied to the payment and Medicaid charge/day/discharge data used in computing the Medicare UPL? | The following options are listed: Yes No |
5 | Are provider taxes included and/or adjusted for in the UPL data (variable 401)? | 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. Insert text Box |
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| Please explain the claims completion factor and its application: | Text Box | 1 | This question was removed as no longer relevant given the other questions asked. | ||
| Section VII. The state UPL data demonstration is structured as follows: | |||||
| The state conducted the UPL demonstration separately for state government owned or operated, non-state government owned or operated and privately owned or operated hospitals. | The following options are listed: Yes No |
2 | This question was removed as no longer relevant given the other questions asked. | ||
| All Medicaid base and supplemental payments are included in the demonstration and are separately identified. | The following options are listed: Yes No |
3 | This question was removed as no longer relevant given the other questions asked. | ||
| The data demonstration only includes in-state hospitals. | The following options are listed: Yes No |
4 | This question was removed as no longer relevant given the other questions asked. | ||
| If the state includes out of state hospitals in the UPL calculation, please verify that data on cost/payments have been obtained from the cost report of the out of state hospitals and that the hospitals are included in the “private” provider category. | The following options are listed: Yes No |
5 | This question was removed as no longer relevant given the other questions asked. | ||
| Are Critical Access Hospitals (CAHs) included? | The following options are listed: Yes No |
6 | This question was removed as no longer relevant given the other questions asked. | ||
| Describe how the state accounts for CAHs in the UPL calculation? | Text Box | 7 | This question was removed as no longer relevant given the other questions asked. | ||
| If CAHS are excluded, please explain the decision to exclude them from the UPL and the basis for demonstrating compliance with 42 CFR 447.272. | Text Box | 8 | This question was removed as no longer relevant given the other questions asked. |
| Section No. | UPL Guidance Question (ORIGINAL) | Response (ORIGINAL) | No. | UPL Guidance Question (UPDATED) | Response or Follow-Up Questions (UPDATED) |
| Section I. The basis of the UPL formula: | Section I: UPL Demonstration Overview | ||||
| The following check boxes are listed: Cost-Based Demonstration (e.g. Cost-to-charge ratio X Medicaid covered O/P charges) or Payment-Based Demonstration (e.g. Payment-to-charge ratio X Medicaid covered O/P charges) Other (please describe below): Text Box |
1 | Are there any significant changes to the prior year UPL methodology? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text Box |
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| Please provide a general description of the formula: | Text Box | 2 | Does the UPL demonstration align with your state fiscal year? | Insert the following options: Yes No If 'No' is selected, insert the following question:: If No, please explain. Insert Text box Add the following note: The UPL demonstration period should start the day after the previous UPL demonstration period’s end date. |
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| Section II. The source of the UPL Medicare equivalent data is: | 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). |
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 |
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| The following check boxes are listed: The Medicare Cost Report (CMS 2552) Filed Settled Other Data Source (Please describe) Text Box |
4 | Does the UPL demonstration include a full 12 months of data for each provider? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text Box |
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| What is the time period of the data? | Base year data: Text Box Rate year data: Text Box |
5 | Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text box |
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| Section III. The state uses the cost report references below: | 6 | Has the provider count (providers enrolled in the Medicaid program and included in the UPL demonstration) changed from the previous UPL demonstration? | Insert the following options: Yes No |
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| Cost-Based Demonstration (Cost-to-Charge Ratio): | The following options are listed: Worksheet C Worksheet D |
6a | Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data. | Insert Text Box | |
| Describe which columns and lines that are used to determine the cost-to-charge ratios. | Text Box | 6b | Please list any changes in the provider category designations (SGO, NSGO, and Private). | Insert Text Box | |
| Payment-Based Demonstration (Payment to Charge Ratio): | The following option is listed: Worksheet E, Part B (Payments) / Worksheet D, Part V and VI (Charges) |
7 | Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for outpatient hospital services. | Insert Text Box | |
| Describe which columns and lines that are used to determine the payment-to-charge ratios. | Text Box | Section II: The source of the UPL Medicare Equivalent Data is: | |||
| Does the Medicare payment data represent gross reported payment or are adjustments made to the data to capture the net payment? | The following options are listed: Gross Net |
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. If 'Other Data Source' is selected, insert the following question: If the UPL Medicare equivalent data is from a different source, please describe. Insert text box. |
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| For net reported payments, 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). | Text Box | 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. |
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 |
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| Other Cost Report Worksheeta, Columns and Lines used: If the state uses other worksheets, describe them and how they are applied. |
Text Box | Section III: The State uses the Cost Report References below: | |||
| Section IV. The State applies the Medicaid charge data, as described below to the Medicare charge ratio: | 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. If Worksheet D is selected, insert the following information: Describe which columns and lines that are used to determine the cost-to-charge ratios. Insert text box |
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| The following check boxes are listed: The Medicaid charges are from paid claims reported from the MMIS. The Medicaid charges are from another source. Other source: _____________. Do the dates of service for the Medicaid charge/day/discharge data match the dates of services from the Medicare cost report data? If no, please explain. |
2 | Payment-to-Charge Demonstration (Payment to Charge Ratio) | 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. 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. Insert text box. |
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| Does the state only include Medicaid charges from in-state Medicaid residents? | The following options are listed: Yes No |
3 | Does the Medicare payment data represent gross reported payment or are adjustments made to the data to capture the net payment? | 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). Insert Text box |
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| Does the charge data exclude crossover claims? | The following options are listed: Yes No |
Section IV: The State applies the Medicaid charge data, as described below to the Medicare charge ratios: | |||
| Are physicians and other professional services excluded? | The following options are listed: Yes No |
1 | Are the Medicaid covered charges/days from paid claims reported from the MMIS? | Insert the following options: Yes No If No is selected, insert the following question: Please name the other source. Insert text Box |
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| Please explain the inclusion of any professional service charges and verify that those services as covered, paid and billed as Medicaid outpatient hospital service payments in accordance with the State's approved State plan methodology. | Text Box | 2 | Do the dates of service for the Medicaid charge data match the dates of services from the Medicare cost report data? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box |
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| Section V. The UPL demonstration applied Medicaid payment data as follows: | 3 | Does the state only include Medicaid charges from in-state Medicaid providers? Note: If the state includes Medicaid charges from out-of-state, please place the provider in the private ownership category. (Variable 110) |
Insert the following options: Yes No |
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| Medicaid base payment data is reported from the MMIS. | The following options are listed: Yes No |
4 | 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. |
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. Insert Text box |
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| If the source of the payment data is a different source, please explain. | Text Box | 5 | Are physicians and other professional services excluded? | 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. Insert Text box |
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| Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period? | The following options are listed: Yes No |
Section V: The UPL demonstration applies Medicaid payment data as follows: | |||
| If no, please explain: | Text Box | 1 | Are Medicaid base payment data reported from the MMIS? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain the source of the payment data. Insert Text box |
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| Medicaid payment data includes ALL base and supplemental payments to outpatient hospital providers. Base and supplemental payments must be separately identified. Note: any reimbursement paid outside of the MMIS should be included. | The following options are listed: Yes No |
2 | Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and the hospital cost reporting period? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert text box |
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| Please explain payments that are made outside of the MMIS. | Text Box | 3 | Does the Medicaid payment data include ALL base and supplemental payments to outpatient hospital providers? | 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. Insert Text Box |
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| Medicaid payment data exclude crossover claims. | The following options are listed: Yes No |
4 | 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. |
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. Insert Text Box |
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| Is the Medicaid payment reported gross or net of primary care payments, deductibles and co-pays? | The following options are listed: Gross Net |
5 | Is the Medicaid payment reported gross or net of the primary payer payments, deductibles, and co-pays? | 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. |
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| Describe how Medicaid payment rate changes between the base period and the UPL period are accounted for in the demonstration? | Text Box | 6 | Describe how Medicaid payment rates change 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. |
Please describe: Insert text box. |
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| Does the dollar amount of payments for the UPL base period equal the "claimed" amounts on the CMS-64, Medicaid Expenditures report for the UPL time period? | The following options are listed: Yes No |
6a | Are all adjustments related to SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration? | Insert the following options: Yes No If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box |
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| If no, please provide a reconciliation and explanation of the difference? | Text Box | Section VI: The State trends or adjusts the UPL data, as follows: | |||
| Section VI. The State trends and adjusts the UPL Data, as below: | 1 | Does the state trend the UPL for inflation? | 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). Insert Text box |
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| The state trends the UPL inflation | The following options are listed: Yes No |
1a | Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box |
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| Explain the trending factor and its source. | Text Box | 2 | 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 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: Insert Text box |
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| Is the inflation trend applied from "mid-point to the mid-point" in order to most accurately project future experience? | The following options are listed: Yes No |
3 | Are there any additional trends or factors for the UPL (not for the Medicaid payments) that are used in the UPL demonstration and their application? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain all additional trends or factors for the UPL. Insert Text box |
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| The state trends the UPL for volume/utilization | The following options are listed: Yes No |
4 | 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? | 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. Insert text box |
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| Explain the volume/utilization adjustment, including: how it will assure the UPL does not over or understate the volume of Medicaid inpatient hospital services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data: | Text Box | 5 | Does the state apply a claims completion factor to the payment data? | Insert the following options: Yes No |
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| Please explain all additonal trends or factor that are used in the demonstration and their application: | Text Box | 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)? | 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 Insert Text Box |
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| Does the state apply a claims completion factor to the payment data? | The following options are listed: Yes No |
Section VII: The State UPL data demonstration is structured as follows: | |||
| Please explain the claims completion factor and its application: | Text Box | 1 | Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL 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. |
Please explain: Insert text box |
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| Does the state apply a claims completion factor to the charge data? | The following options are listed: Yes No |
2 | Does the demonstration include all outpatient hospitals that receive payments under Medicaid? | Insert the following options: Yes No |
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| Please explain the claims completion factor and its application: | Text Box | 3 | Does the demonstration only include in-state hospitals? | Insert the following options: Yes No 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. |
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| Is the claims completion factor equally applied to the payment and charge data? | The following options are listed: Yes No |
4 | Are provider taxes included and/or adjusted for in the UPL data (variable 401)? | 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. Insert text Box |
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| Section VII: The state UPL data demonstration is structured as follows: | |||||
| The state conducted the UPL demonstration separately for state government owned or operated, non-state government owned or operated and privately owned or operated hospitals. | The following options are listed: Yes No |
1 | This question was removed as no longer relevant given the other questions asked. | ||
| All Medicaid base and supplemental payments are included in the demonstration and are separately identified. | The following options are listed: Yes No |
2 | This question was removed as no longer relevant given the other questions asked. | ||
| The demonstration includes all facilities that receive outpatient hospital payments under Medicaid. | The following options are listed: Yes No |
3 | This question was removed as no longer relevant given the other questions asked. | ||
| The demonstration only includes in-state hospital | The following options are listed: Yes No |
4 | This question was removed as no longer relevant given the other questions asked. | ||
| If the state includes out of state hospitals in the UPL calculation, please verify that data on cost/payments have been obtained from the cost report of the out of state hospitals and include the hospitals in the “private” bucket for purposes of the UPL. | The following options are listed: Yes No |
5 | This question was removed as no longer relevant given the other questions asked. | ||
| Are Critical Access Hospitals included? | The following options are listed: Yes No |
6 | This question was removed as no longer relevant given the other questions asked. | ||
| Describe how the state accounts for CAHs in the UPL calculation? | Text Box | 7 | This question was removed as no longer relevant given the other questions asked. | ||
| If CAHS are excluded, please explain the decision to exclude them from the UPL and the basis for demonstrating compliance with 42 CFR 447.321. | Text Box | 8 | This question was removed as no longer relevant given the other questions asked. |
| Section No. | UPL Guidance Question (ORIGINAL) | Response (ORIGINAL) | No. | UPL Guidance Question (UPDATED) | Response or Follow-Up Questions (UPDATED) |
| Section I. The Basis of the UPL Formula is: | Section I: UPL Demonstration Overview | ||||
| The following check boxes are listed: Cost-Based Demonstration (e.g. Routine per diem X Medicaid covered days, and Cost-to-charge ratio X Medicaid covered NF charges) or Medicaid Nursing Facility Cost Report Demonstration, or Medicare Resource Utilization Group (RUGs) Payment Demonstration Other (please describe below): Text Box |
1 | Are there any significant changes to the prior year UPL methodology? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text Box |
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| Please provide a general description of the formula: | 2 | Does the UPL demonstration align with your state fiscal year? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box Add the following note: Note: The UPL demonstration period should start the day after the previous UPL demonstration period’s end date. |
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| Section II. The source of the UPL Medicare equivalent data is: | 3 | Does the UPL demonstration trend data from the previous UPL demonstration submission or does it contain new data? | 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 |
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| The following check boxes are listed: The Medicare Cost Report (CMS 2540 and 2552 for hospital-based NF services) Filed Settled State Nursing Facility Cost Report Filed Settled Medicare Resource Utilization Group (RUGs) Other Data Source (Please describe) Text Box |
4 | Does the UPL demonstration include a full 12 months of data for each provider? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text Box |
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| What is the time period of the data? | Base year data: Text Box Rate year data: Text Box |
5 | Is the beginning date of the data more than 2 years from the beginning date of the UPL demonstration period? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert Text box |
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| Is the data the most recently available to the state? | The following options are listed: Yes No |
6 | Has the provider count changed from the previous UPL demonstration? | Insert the following options: Yes No |
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| Section III. The State uses the Medicare Cost Report to Calculate the Medicare Equivalent: | 6a | Please explain the changes, including any new providers, closed providers, or mergers. | Insert Text Box | ||
| Cost-Based Demonstration: (Sub-section) | 6b | Please list any changes in the provider category designations (SGO, NSGO, and Private). | Insert Text Box | ||
| CMS 2552: The following check boxes are listed: Worksheet B (costs) Worksheet C (cost and changes) Worksheet D-1 (per diems) CMS 2540: The following check boxes are listed: Worksheet B (costs) Worksheet C (ancillary cost and ancillary charges) Worksheet D-1 (per diems) |
Text Box | 7 | Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for nursing facility services. | Insert Text Box | |
| Describe which columns and lines that are used to determine the cost-to-charge ratios and the routine per diem amounts used in the cost-based UPL. | Section II: The Source of the UPL Medicare equivalent data is: | ||||
| Other Cost Report Worksheets, Columns and Lines used: (Sub-section) | 1 | What is the source of the UPL Medicare Equivalent Data? | Note: Insert one of the below text for "Filed" and "Settled" as it applies. The data from the Medicare Cost reports are Filed and Settled. (If both “Filed and Settled” are shown in the data) The data from the Medicare Cost reports are Filed. (If only "Filed" is shown in the data) The data from the Medicare Cost reports are Settled. (If only "Settled" is shown in the data) Insert the following options: User can choose more than one option. The Medicare Cost Report (CMS 2540 and 2552 for hospital-based NF services) If Medicare Cost Report (CMS 2540 and 2552) is selected, Navigate the user to the below Sub header: Sections III and IV should not be available to the user. State Developed Nursing Facility Cost Report If State Developed Nursing Facility Cost Report is selected, then Section IV should not be available to the user. Medicare Resource Utilization Group (RUGs) If Medicare Resource Utilization Group (RUGs) is slected, then Section III should not be available to the user. Patient Driven Payment Method (PDPM) When 'The Medicare Cost Report' is selected, insert the following: Sub Header: The State Uses the Medicare Cost Report to Calculate the Medicare Equivalent: Cost-Based Demonstration using Medicare Cost Report 1. Please select the worksheet(s) that apply. (More than one option can be selected) Insert the following options to select: Total All-Payer Cost (SNF Routine Cost): When this option is chosen please make the following note available: "In the NF Cost Template, cost per diem is used to calculate the UPL from the cost report period. Where total all-payer SNF routine cost is used, it is divided by the total all-payer inpatient SNF days". If this option is selected, insert the following options: CMS 2540: WKST B, Part I, Column 18, Line 30 CMS 2552: WKST B, Part I, Column 26, Line 44 Total All-Payer Cost (NF Routine Cost): When this option is chosen please make the following note available: "In the NF Cost Template, cost per diem is used to calculate the UPL from the cost report period. Where total all-payer NF routine cost is used, it is divided by the total all-payer inpatient NF days". If this option is selected insert the following options: CMS 2540: WKST B, Part I, Column 18, Line 31 CMS 2552: WKST B, Part I, Column 26, Line 45 Medicare Program Inpatient Cost (SNF Routine Cost) When this option is chosen please make the following note available: "In the NF Cost Template, cost per diem is used to calculate the UPL from the cost report period. Where Medicare program inpatient SNF routine cost is used, it is divided by Medicare program inpatient SNF days". If this option is selected insert the following options: CMS 2540: WKST D-1, Part I (Title XVIII), Column 1, Line 28 CMS 2552: WKST D-1, PART III (Title XVIII), SNF), Column 1, Line 83 Medicare Program Inpatient Payment (SNF-PPS plus pass through plus utilization review) When this option is chosen please make the following note available: "In the NF Per Diem Template, Medicare program inpatient payment per diem is used to calculate the UPL from the cost report period. Medicare program inpatient SNF payment is divided by Medicare program inpatient SNF days. Medicare SNF PPS payment includes payment for ancillary services. States will need to account for ancillary services included in Medicare SNF-PPS that are not reimbursed by the state's Medicaid NF reimbursement methodology under Attachment 4.19-D". If this option is selected insert the following options: CMS 2540: WKST E, Part I, Column 1, Line 3 plus Line 10 (if Gross Payments) CMS 2540: WKST E, Part I, Column 1, Line 11 (if Net Payments) CMS 2552: WKST E-3, Part VI, Column 1, Line 4 plus Line 11 (if Gross Payments) CMS 2552: WKST E-3, Part VI, Column 1, Line 12 minus Line 13 (if Net Payments) Medicare Program Inpatient Days (SNF) When this option is chosen please make the following note available: "In the NF Cost Template, this is used in the cost per diem to calculate the UPL from the cost report period. In the NF Per Diem Template, it is used in the payment per diem to calculate the UPL from the cost report period. The Medicare program inpatient SNF days correspond to the Medicare program inpatient SNF payments or routine cost". If this option is selected insert the following options: CMS 2540: WKST S-3, Part I, Column 4, Line 1 CMS 2552: WKST S-3, Part I, Column 6, Line 19 Total All-Payer Inpatient Days (SNF) When this option is chosen please make the following note available: "In the NF Cost Template, it is used in the cost per diem to calculate the UPL from the cost report period. Total all-payer inpatient SNF days correspond to total all-payer inpatient SNF routine cost". If this option is selected insert the following options: CMS 2540: WKST S-3, Part I, Column 7, Line 1 CMS 2552: WKST S-3, Park I, Column 8, Line 19 Total All-Payer Inpatient Days (NF) When this option is chosen please make the following note available: "In the NF Cost Template, it is used in the cost per diem used to calculate the UPL from the cost report period. Total all-payer inpatient NF days correspond to total all-payer inpatient NF routine cost". If this option is selected insert the following options: CMS 2540: WKST S-3, Part I, Column 7, Line 1 CMS 2552: WKST S-3, Part I, Column 8, Line 20 Sub Header: Other Cost Report Worksheets, Columns and Lines 1. If the state uses other worksheets, please describe which worksheets, parts, columns, and lines that are used to determine the costs, charges, and the routine per diem amounts used in the cost-based UPL. Insert text box 2. Are the ancillary and routine Medicare costs determined per facility? Insert the following options: Yes No If "No" is selected, then insert the following question: If No, please explain why. Insert Text box 3. Did the state make necessary adjustments to account for differences in Medicare and Medicaid costs and charges? (e.g. reduces Medicare costs and charges for drugs) Insert the following options: Yes No If 'Yes' is selected, insert the following question: Please explain the adjustments. Insert text box Sub Header: The state applies Medicaid ancillary charge data, as described below to the Medicare ancillary charge ratios 1. Are the Medicaid covered charges from paid claims reported from the MMIS? Insert the the following options: Yes No If 'No' is selected, insert the following question: Please identify and describe the other source. Insert text box 2. Do that dates of service for the Medicaid ancillary charge data match the dates of services from the Medicare cost report data? Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert text box 3. Does the state only include Medicaid charges from in-state Medicaid residents? Insert the following options: Yes No 4. 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. Insert the following options: Yes No 5. Are physicians and other professional service charges excluded? Insert the following options: Yes No If 'No' is selected, insert the following question: Please explain the inclusion of any professional service charges and verify that those services are covered, billed, and paid as Medicaid nursing facility service payments in accordance with the state's approved State Plan methodology. Insert text box Sub Header: The state calculates Medicare routine cost per diem for each facility 1. Please describe the calculation for Medicare routine cost per diem for each facility. Insert text box 2. What is the source of the Medicaid covered days? Insert the following options: Paid claims reported from the MMIS State nursing facility cost report If 'State nursing facility cost report' is selected, insert the following question: Please identify the worksheets, parts, columns, and lines from the state nursing facility cost report. Insert text box |
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| If the state uses other worksheets, describe them and how they are applied. | Text Box | 2 | What is the time period of the data? Note: 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. |
This will be Read-only for the user. 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 |
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| The following check box is listed: The ancillary and routine Medicare costs are determined per facility. |
3 | Is the data the most recently available to the state? | Insert the following options: Yes No |
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| The state makes necessary adjustments to account for differences in Medicare and Medicaid costs and charges (e.g. reduces Medicare cost and charges for drugs) | The following options are listed: Yes No |
Section III: Cost-Based Demonstration using State Developed Nursing Facility Cost Report | |||
| Explain the adjustments? | Text Box | 1 | Please describe the cost report and provide a cross walk of the worksheets, columns, and lines to the equivalent worksheets, columns, and lines reported on the Medicare 2540 or 2552. Please fully detail any variation between the state's cost report and the Medicare cost report. | Insert text box | |
| The State applies Medicaid ancillary charge data, as described below to the Medicare ancillary charge ratios: (Sub-section) | 2 | Please describe the state calculation for Medicare-equivalent cost per diem for each facility. | Insert text box | ||
| The following check boxes are listed: The Medicaid covered charges are from paid claims reported from the MMIS The Medicaid covered charges are from another source |
3 | Please describe the treatment of capital expenditures. | Insert text box | ||
| Other source and description: | Text Box | 4 | What is the source of the Medicaid covered days? | Insert the following options: Paid claims reported from the MMIS State nursing facility cost report If 'State nursing facility cost report' is selected, insert the following question: Please identify the worksheets, columns, and lines from the state nursing facility cost report. Insert text box |
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| Do the dates of service for the Medicaid ancillary charge data match the dates of services from the Medicare cost report data? If no, please explain. |
Text Box | Section IV: Medicare Resource Utilization Group (RUGs) | |||
| Does the state only include Medicaid charges from in-state Medicaid residents? | The following options are listed: Yes No |
1 | Describe the version of the RUGs case-mixed classification system used in the demonstration and the calculation of the Medicare equivalent payment. | Insert text box | |
| Does the charge data exclude crossover claims? | The following options are listed: Yes No |
2 | Describe all adjustments the state makes to account for variation between the Medicare RUGs system and the state's Medicaid nursing facility reimbursement policy. | Insert text box | |
| Are physicians and other professional service charges excluded? | The following options are listed: Yes No |
Section V: The UPL demonstration applies Medicaid payment data as follows: | |||
| Please explain the inclusion of any professional service charges and verify that those services as covered, billed and paid as Medicaid nursing facility service payments in accordance with the State's approved State plan methodology. | Text Box | 1 | Are Medicaid base payment data reported from the MMIS? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain the source of the payment data. Insert text box |
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| The State calculates Medicare routine cost per diem for each facility: (Sub-section) | 2 | Does the Medicaid payment data includes ALL base and supplemental payments to nursing facility providers? | 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. Insert Text Box |
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| Describe the calculation: | Text Box | 3 | Do Medicaid payment data exclude crossover claims? | 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. Insert Text Box |
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| The following check boxes are listed: The source of Medicaid covered days are from paid claims reported from the MMIS. The source of the Medicaid covered days are the worksheets, columns and lines listed below from a state nursing facility cost report: Text Box |
4 | Is the Medicaid payment reported gross or net of deductibles and co-pays? | Insert the following options: Gross Net |
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| Section IV: The State uses a Medicaid State Nursing Facility Cost Report to Calculate the Medicare Equivalent: | 5 | 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. |
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| Describe the cost report and provide a crosswalk of the worksheets, lines and columns to the equivalent worksheets, lines and columns reported on the Medicare 2552 or 2540. Please fully detail any variation between the state's cost report and the Medicare cost report. | Text Box | 5a | Are all adjustments related to SPAs between the Medicaid data base period and UPL demonstration period accounted for in the demonstration? | Insert the following options: Yes No If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box |
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| Describe the treatment of capital expenditures: | Text Box | Section VI: The State trends or adjusts the UPL data, as follows: | |||
| The State calculates Medicare-equivalent cost per diem for each facility: Describe the calculation: |
Text Box | 1 | Does the state trend the UPL for inflation? | 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). Insert text box |
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| The following check boxes are listed: The source of the Medicaid covered days are the worksheets, columns and lines listed below from a state nursing facility cost report: Text Box The source of the Medicaid covered days are paid claims reported from the MMIS. |
2 | Does the state trend using the RUGs frequency distribution for each facility? | Insert the following options: Yes No If 'Yes' is selected, insert the following question: Please describe the application of the frequency distribution. |
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| Section V. The State uses Resources Utilization Groups to Calculate the Medicare Equivalent: | 3 | Is the inflation factor trend applied from mid-point to mid-point in order to most accurately project future experience? | Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text box |
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| Describe the version of the RUGs case-mixed classification system used in the demonstration and the calculation of the Medicare equivalent payment: | Text Box | 4 | 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 volume/utilization adjustment, including: How it will assure the UPL does not over or understate the volume of Medicaid nursing facility services provided in the rate year? How it is applied? Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data. Insert text box |
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| Describe all adjustments the state makes to account for variation between the Medicare RUGs system and the state's Medicaid nursing facility reimbursement policy: | Text Box | 5 | Does the state apply a claims completion factor to the payment data? | 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. Insert text box |
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| Section VI. The UPL demonstration applies Medicaid payment data as follows: | 6 | Does the state apply a claims completion factor to the day/charge data? | 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. Insert text box |
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| Medicaid base payment data is reported from the MMIS. | The following options are listed: Yes No |
7 | Is the claims completion factor equally applied to the payment and day/charge data? | 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. Insert text box |
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| If the source of the payment data is a different source, please explain: | Text Box | Section VII: The State UPL data demonstration is structured as follows: | |||
| Medicaid payment data includes ALL base and supplemental payments to nursing facility providers. Base and supplemental payments must be identified separately. Note: any reimbursement paid outside of MMIS should also be included (e.g. quality incentive payments.) | The following options are listed: Yes No |
1 | Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL demonstration for each applicable provider category (SGO, NSGO, and Private). | Please explain: Insert Text Box |
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| Please explain payment that are made outside of the MMIS. | Text Box | 2 | Does the demonstration include all nursing facilities that receive payments under Medicaid? | Insert the following options: Yes No If "No" is selected, insert the following question: If No, please explain which nursing facilities that received payments from Medicaid are not included and why. Insert text box |
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| Medicaid payment data exclude crossover claims. | The following options are listed: Yes No |
3 | Does the data demonstration only include in-state nursing facilities? | Insert the following options: Yes No If "No" is selected, insert the following question: If No, the nursing facilities 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 nursing facility. Out-of-state nursing facilities are included in the "private" provider category. Cost and payment data is obtained from the cost report of the out-of-state nursing facility. |
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| Is the Medicaid payment reported gross or net of deductibles and co-pays? | The following options are listed: Gross Net |
4 | Are provider taxes included and/or adjusted for in the UPL data (variable 401)? | 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. Insert text Box |
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| Describe how Medicaid payment rate changes between the base period and the UPL period are accounted for in the demonstration. | Text Box | ||||
| Does the dollar amount of payments for the UPL base period equal the "claimed" amounts on the CMS-64, Medicaid Expenditures report for the UPL time period? | The following options are listed: Yes No |
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| If no, please provide a reconciliation and explanation of the difference? | Text Box | ||||
| Section VII. The State trends the UPL data, as follows: | |||||
| The State trends the UPL for inflation. | The following options are listed: Yes No |
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| Explain the trending factor and its source. | Text Box | ||||
| The state trends using the RUGs frequency distribution for each facility. | The following options are listed: Yes No |
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| Please describe the application of the frequency distribution | Text Box | ||||
| Is the inflation trend applied from "mid-point to the mid-point" in order to most accurately project future experience? | The following options are listed: Yes No |
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| The State trends the UPL for volume/utilization. | The following options are listed: Yes No |
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| Explain the volume/utilization adjustment, including: how will it assure the UPL does not over or understate the volume of Medicaid nursing facility services provided in the rate year, how it is applied and that it is applied consistently to the Medicare equivalent and Medicaid payment data: | Text Box | ||||
| Does the state apply a claims completion factor to the payment data? | The following options are listed: Yes No |
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| Please explain the claims completion factor and its application: | Text Box | ||||
| Does the state apply a claims completion factor to the day/charge data? | The following options are listed: Yes No |
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| Please explain the claims completion factor and its application: | Text Box | ||||
| Is the claims completion factor equally applied to the payment and day/charge data? | The following options are listed: Yes No |
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| Section VIII. The State UPL data demonstration is structured as follows: | |||||
| The state conducted the UPL demonstration separately for state government owned or operated, non-state government owned or operated and privately owned or operated nursing facilities. | The following options are listed: Yes No |
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| All Medicaid base and supplemental payments are included in the demonstration and are separately identified. | The following options are listed: Yes No |
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| The demonstration includes all nursing facilities that receive payments under Medicaid? | The following options are listed: Yes No |
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| The data demonstration only includes in-state nursing facilities. | The following options are listed: Yes No |
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| If the state includes out of state hospitals in the UPL calculation, please verify that data on cost/payments have been obtained from the cost report of the out of state hospitals and that the hospitals are included in the “private” provider category. | The following options are listed: Yes No |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |