Questions Logic

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Overview

IMD
ICF IID
PRTF
Clinic
Physician

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Sheet 1: IMD

No.	UPL Guidance Question	Response or Follow-Up Questions
Section I: UPL Demonstration Overview:
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
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.
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).	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
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
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
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 If 'Yes' is selected, insert questions 6a and 6b
6a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	Insert Text Box
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	Insert Text Box
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for IMD services.	Insert Text Box
Section II: The source of the UPL Medicare Equivalent Data is:
1	What source is used to obtain the Medicare Equivalent data?	Insert the following options: Cost Reports, check all that apply: The Medicare Hospital Cost Report (CMS 2552-10) The Medicare Skilled Nursing Facility Cost Report (CMS 2540-10) State Developed Cost Report utilizing Medicare Cost Principles from 45 CFR 75 Other If user selects "Other" then add questions 1a and 1b.
1a	If Other, please fully explain the date source(s) and how the data is used.	Please describe: Insert text box
1b	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
2	How the price-based demonstration adjusts for differences in Medicare and Medicaid patient acuity?	Insert the following options: Yes No If 'Yes' is selected, insert the following question: Please explain: Insert Text Box
3	What is the time period of the data? Note: The response to this question is auto-generated based on the data in the IMD UPL submission. Base year data means the 12 month period (this is a date range input) for which the state has Medicaid and Medicare data that serves as the baseline for the UPL demonstration. Rate year data means the 12 month period (this is a date range input) for which the UPL demonstration is being performed. The rate year should be the current UPL demonstration year.	The below text is Read-only for the user: Base Year Data: MCR Begin Date Begin Date for Charge, Cost or Payment Data: System populated field in variable 200.1 MCR End Date End Date for Charge, Cost or Payment Data: System populated field in variable 200.2 MCD Days Begin Date: System populated field in variable 300.1 MCD Days End Date: System populated field in variable 300.2 MCD Rates Begin Date: System populated field in variable 311.1 MCD Rates End Date: System populated field in variable 311.2 Rate Year Data: State Demonstration Rate Year: System populated field in SFY Demo Begin Date: System populated field in variable 002 Demo End Date: System populated field in variable 003
Section III: The State uses the Cost Report References below:
1	Indicate which cost report is used and which Worksheets, Parts, Columns, and Lines are used to populate the data.	Insert Text Box
2	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, 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
Section IV: The State applies the Medicaid charge or day data to the Medicare per diem amounts as described below:
1	Are the Medicaid covered charges and days from paid claims reported from MMIS?	Insert the following options: Yes No If No is selected insert the following: If No, please name the other source. Insert text Box
2	Do the dates of service for the Medicaid charge and day data [variable 300.1 and variable 300.2] match the dates of services from the Medicare cost report data [variable 200.1 and variable 200.2]?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain why. Insert Text box
3	Does the state only include Medicaid charges from in-state Medicaid providers residents? Note: If the state includes Medicaid charges or days from out-of-state, please place the provider in the private ownership category (Variable 110).	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 If No is selected insert the following: Explain how including the crossovers would provide a more relevant estimate. If included, please explain the inclusion of all IMD service charges and verify that those services are covered, billed, and paid as Medicaid IMD service payments in accordance with the approved state plan IMD reimbursement methodology. Insert Text box for this explanation.
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 IMD service payments in accordance with the approved state plan IMD reimbursement methodology. If the services are not covered, billed, and paid as Medicaid IMD service payments then the data for these services should be removed from the IMD UPL demonstration. Insert Text box
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
2	Are the dates of service for the Medicaid payment data consistent with the Medicaid charge/day data and the IMD cost reporting period?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text Box
3	Does the Medicaid payment data include ALL base and supplemental payments to IMD providers?	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
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 No, please explain the source of any payments that are made outside of the MMIS. Insert Text Box
5	Is the Medicaid payment reported gross or net of the primary payer payments, deductibles, and co-pays?	Insert the following checkbox: I confirm that the Medicaid payment data are reported in the same manner as Medicare payment data in "Section III, question 2" or "Section II, question 1b".
6	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.	Please describe: Insert text box
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 If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box
Section VI: The State trends or adjusts the UPL data, as follows:
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
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
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 IMD services provided in the rate year? How it is applied? Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data. Please explain: Insert Text box
3	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
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 or day 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
5	Does the state apply a claims completion factor to the payment data?	Insert the following options: Yes No If 'Yes' is selected, proceed to question 5a
5a	If Yes, is the claims completion factor equally applied to the payment and Medicaid charge or day 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
Section VII: The state UPL data demonstration is structured as follows:
1	Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL 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
2	Does the demonstration include all IMDs that receive payments under Medicaid?	Insert the following options: Yes No
3	Does the UPL demonstration only include in-state IMDs?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, the IMDs should be included in the "private" provider category. The state should also verify that cost/payment data is obtained from the cost report of the out-of-state IMD. Out-of-state IMDs are included in the "private" provider category. Cost and payment data are obtained from the cost report of the out-of-state IMD.
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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Sheet 2: ICF IID

No.	UPL Guidance Question (UPDATED)	Response or Follow-Up Questions (UPDATED)
Section I: UPL Demonstration Overview
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
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.
3	Does the UPL demonstration trend data from the previous UPL demonstration submission or does it contain new data? If using trended data, please specify which data variables are trended. Note: Trended data may only include variable 211 (Medicare Per Diem).	Insert the following options: Data trended from previous submission Insert Text Box 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
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
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
6	Has the provider count changed from the previous UPL demonstration?	Insert the following options: Yes No If 'Yes, proceed to questions 6a and 6b.
6a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	Insert Text Box
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	Insert Text Box
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for ICF/IID services.	Insert Text Box
Section II: Source of the UPL Medicare Equivalent Data is:
1	What is the basis of the UPL formula?	Insert the following the options: Medicaid Cost Demonstration Using Medicare Cost Finding Principles Other If 'Other' is selected, insert the following question: If Other, please describe. Insert Text Box
2	What is the time period of the data used in the demonstration, including the beginning and ending dates? Note: The response to this question is auto-generated based on the data in the ICF/IID 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 below options and text are Read-only for the user: Base Yeas 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 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
3	Is the data the most recently available to the state?	Insert the following options: Yes No
Section III. Medicare cost comparison is verified as described below:
1	What is the source of the UPL Medicare equivalent data?	Insert the following options: State Developed Cost Report using Medicare Cost Identification Principles Modified Medicare Skilled Nursing Facility Cost Report (CMS 2540) When user selects Modified Medicare Skilled Nursing Facility Cost then display Question 5 from Cost Report Development sub-section. Insert the following question: a. If the state uses a modified Medicare SNF report, does the state capture the same types of allowable costs as reported on the Medicare SNF cost report? Insert the following options: Yes No If 'No' is selected, proceed to questions a1 and a2. a1. Has the state documented and explained the cost category discrepancies? Insert the following options: Yes No a2. Please explain all discrepancies and modifications to the SNF cost report. Insert Text Box
Cost Report Development (Sub-section)
1	Does the cost report recognize allowable and non-allowable costs in accordance with Medicare Cost Principles in 42 CFR 413 and 45 CFR 75?	Insert the following options: Yes No If "No" is selected, insert the following question: If No, please explain the treatment and allocation of costs. The state will need to discuss with CMS whether this methodology is acceptable. Insert Text Box
2	Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?	Insert the following options: Yes No If "No" is selected, insert the following note: CMS may request that the state submit the cost report for review prior to any acceptance of the submitted UPL demonstration.
3	Do providers submit the cost reports to the State Medicaid agency annually?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please describe. Insert Text Box
4	Is the cost report audited by the state agency or through an independent audit?	Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, what is the frequency of the audit? Insert Text Box
Cost Finding Methodology (Sub-section)
1	Please describe the cost identification and allocation process (including the recognized direct costs, treatment of indirect cost, all allocation methods used to determine the costs related to Medicaid services). If the cost identification and allocation process are different from Medicare Cost Principles then please explain.	Insert Text Box
2	Are indirect/overhead costs and direct service costs separately identified on the cost report?	Insert the following options: Yes No
3	Are both routine and ancillary service costs identified on the cost report?	Insert the following options: Yes No
4	Are ancillary service costs separately identified on the cost report?	Insert the following options: Yes No
4a	Please describe how the routine and ancillary costs are reported in the cost report and how they are treated for the purpose of determining Medicaid ICF/IID cost.	Insert Text Box
5	Are Central Office or related entity costs allocated to the ICF/IIDs?	Insert the following options: Yes No There are no Central Office or related entity costs. If 'Yes' or 'No' is selected, proceed to question 5a.
5a	Please describe how Central Office or related entity costs are identified in the cost report and are allocated to represent actual Medicaid incurred cost.	Insert Text Box
Application of Medicaid days to per diem cost (applies to both state-developed cost report and Medicare-based cost report) (Sub-section)
1	Does the cost report arrive at an ICF/IID cost per diem for each facility and apply Medicaid days to the per diem?	Insert the following options: Yes No
2	For the determination of cost used for the per diem, is cost exclusive or inclusive of cost associated with non-certified beds?	Insert the following options: Exclusive Inclusive
3	Have the per diem cost and/or Medicaid rates been adjusted for low occupancy?	Insert the following options: Yes No
4	Is the per diem ICF/IID cost inclusive of all routine and ancillary services?	Insert the following options: Yes No
5	Does the state use paid claims data from the MMIS as the source of the Medicaid days?	Insert the following options: Yes No
6	Are the Medicaid days used in the UPL calculation from the same period as the cost report period?	Insert the following options: Yes No If 'No' is selected insert the following question: If No, please explain why they are different. Insert Text Box
Section IV. Source of the Medicaid Payment Data
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
2	Does the Medicaid payment data include ALL base and supplemental payments to ICF/IID 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
3	Are the dates of service for the Medicaid payment data consistent with the Medicaid cost reporting period?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain. Insert Text Box
4	Where the state makes Medicaid payment outside of Attachment 4.19-D for other services furnished to ICF/IID residents, are these Medicaid payments excluded from the UPL demonstration?	Insert the following options: Yes No
4a	If applicable, please explain any excluded Medicaid payments that are made outside of 4.19-D. Also please explain how their related costs are excluded from the computation of the cost UPL. Note: If not applicable, then indicate "N/A" in the response.	Insert Text Box
5	Does the Medicaid payment data exclude crossover claims? Note: Crossover claims are claims that are both Medicare and Medicaid and are for dual eligible beneficiaries. These claims should be excluded for UPL demonstration purposes because Medicaid only pays the deductible/coinsurance or copay amount of the claim or the difference between the Medicaid and Medicare payment rate if the Medicaid rate is higher. The Medicaid portion of the claim would be much lower as a payer on the claim and would not represent the normal Medicaid payment. As such, the UPL gap would not reflect the true gap.	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
6	Is the Medicaid payment reported gross or net of primary payer payments, deductibles, and co-pays?	Insert the following options: Gross Net
7	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.	Insert Text Box
7a	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 If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box
Section V. 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
1a	Does the state exclude capital costs from the trending?	Insert the following options: Yes No
1b	Is the inflation trend applied from “mid-point to the 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
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 nursing facility ICF/IID services provided in the rate year? How it is applied? Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data. Insert text box
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
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 or day 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
5	Does the state apply a claims completion factor to the payment data?	Insert the following options: Yes No If 'Yes' is selected, proceed to question 5a.
5a	If Yes, is the claims completion factor equally applied to the payment and Medicaid charge or day 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
Section VI. The state UPL data demonstration is structured as follows:
1	Explain any significant increases or decreases in the UPL Gap from the prior year’s UPL 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
2	Does the demonstration include all ICF/IID facilities that receive payments under Medicaid?	Insert the following options: Yes No
3	Does the demonstration only includes in-state ICF/IIDs?	Insert the following options: Yes No If "No" is selected, insert the following question: If No, the ICF/IIDs should be included in the "private" provider category. The state should also verify that cost/payment data are obtained from the cost reports of the out-of-state ICF/IIDs. Out-of-state ICF/IIDs are included in the "private" provider category. Cost and payment data are obtained from the cost report of the out-of-state ICF/IIDs.
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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Sheet 3: PRTF

No.	UPL Guidance Question	Response or Follow-Up Questions
Section I: UPL Demonstration Overview
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
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.
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).	Insert the following options: Data trended from previous submission Insert Text Box 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
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
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
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 If 'Yes' is selected, proceeds to questions 6a and 6b
6a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	Insert text box
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	Insert text box
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for PRTF services.	Insert text box
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.	Insert text box
3	What is the time period of the data? 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.	The below text is Read-only for the user: 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
4	Is the data the most recently available to the state?	Insert the following options: Yes No
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?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please describe the other source(s). Insert Text Box
2	Are the providers' charges uniform for all payers?	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. Insert Text Box
3	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 the differences. Insert Text Box
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 agency?	Insert the following options: Yes No
2	Do the prevailing charge data used in the calculation come from claims data from the MMIS?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please describe the other source(s) and the basis for determining prevailing charges. Insert Text box
3	Describe how the data reflects or is adjusted to account for locality.	Insert text box
4	Describe how the data reflects or is adjusted to represent comparable services under comparable circumstances.	Insert text box
5	Does the demonstration use prevailing charges for the same services that are paid under the Medicaid program?	Insert the following options: Yes No If 'No' is selected, insert the following question: If No, please explain the differences. Insert Text box
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
2	Does the Medicaid payment data include ALL base and supplemental payments to PRTF providers?	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. Insert Text Box
3	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
4	Is the Medicaid payment reported gross or net of the primary payer payments, deductibles and co-pays?	Insert the following options: Gross Net
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.	Insert the following: Please describe. Insert text box.
5a	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 If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box
Section VI: The State trends or adjusts the UPL data, as follows:
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) and why it is an applicable inflation to the customary and/or prevailing charges. Insert 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
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 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: Insert Text box
3	Are there any additional trends or factors for the UPL (not for the Medicaid payments) that are used in the 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
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
5	Does the state apply a claims completion factor to the payment data?	Insert the following options: Yes No If 'Yes' is selected, proceed to question 5a:
5a	If Yes, is the claims completion factor equally applied to the payment and Medicaid 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
Section VII: The state UPL data demonstration is structured as follows:
1	Did the state conduct the UPL demonstration individually for each facility?	Insert the following options: Yes No If "No" is selected, insert the following question: If No, please explain. Insert Text Box
2	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
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. Insert text box
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.

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Sheet 4: Clinic

No.	UPL Guidance Question	Response or Follow-Up Questions
Section I: UPL Demonstration Overview:
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
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.
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 Insert Text Box 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
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
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
6	Has the provider count changed from the previous UPL demonstration?	Insert the following options: Yes No If 'Yes' is selected, proceed to questions 6a and 6b.
6a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	Insert Text Box
6b	Please list any changes in the provider category designations (SGO, NSGO, and Private).	Insert Text Box
7	Indicate the percentage of managed care and FFS in the state’s Medicaid program overall and also for Clinic services.	Insert Text Box
Section II: Description of Clinic services included
1	Does this demonstration apply to all Medicaid freestanding clinics?	Insert the following options: Yes No
1a	Please describe the Medicaid freestanding clinic type(s).	Insert Text Box
State clinic service payment methodology for the services: (Sub-section)
1	Does the state pay a Medicaid fee schedule rates for all services provided by the clinic?	Insert the following options: Yes No
2	Does the state pay clinics a fee schedule amount per CPT billing code using a percentage of the Medicare fee that is currently in effect?	Insert the following options: Yes No If Yes is selected, insert the following options: If Yes, state the percentage(s). Insert Text Box
3	Does the state pay clinics using an encounter rate?	Insert the following options: Yes No If Yes is selected, proceed to question 3A.
3a	If yes, does the state track by CPT or other billing code the individual services that Medicaid beneficiaries actually receive?	Insert the following options: Yes No If No is selected, insert the following options: If No, please explain. Insert Text Box
Demonstration comprehensiveness: (Sub-section)
1	Are all of the Medicaid clinic services provided by the providers listed above in Section II question 1a accounted for in the demonstration?	Insert the following options: Yes No If No is selected, insert the following options: If No, please explain. Insert Text Box
Section III: The basis of the UPL formula is:
1	What is the basis of the UPL formula?	Insert the following options: State payment rate schedule to Medicare RBRVS Comparison Demonstration (Medicare non-facility fee schedule per CPT) Medicaid Cost Demonstration
2	What is the time period of the data used in the demonstration, including the beginning and ending dates? Note: The response to this question is auto-generated based on the data in the Clinic 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 below options and text are Read-only for the user: Base Year Data: UPL Source Begin Date: System populated field in variable 200.1 UPL Source 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
3	Is the data the most recently available to the state?	Insert the following options: Yes No
Section IV: Medicare payment comparison is verified as described below:
1	What is the source of the UPL Medicare equivalent data (200-level series variables in the template)?	Insert the following options: Medicare Fee Schedule
1a	Is the Medicare fee schedule for the same time period as the Medicaid payment data?	Insert the following options: Yes No
1b	What is the date of the Medicare fee schedule that is used in the demonstration?	Insert Text Box
Identification of Medicare Equivalent Codes: (Sub-section)
1	Are all Medicaid services linked to a Medicare-equivalent CPT code?	Insert the following options: Yes No If No is selected, insert the following options and proceed to question 1a. If No, please explain and provide a crosswalk between CPT and local codes. Insert Text Box
1a	If the services are not directly comparable to a Medicare payment for a particular billing code, can the state demonstrate a reasonably equivalent Medicare code to compare to the Medicaid payment?	Insert the following options: Yes No If Yes is selected, insert the following options: If Yes, please explain the Medicare codes, or equivalent codes, used in the demonstration and the equivalent Medicaid payment. Insert Text Box
2	Does the state apply Medicaid volume of service rendered within the demonstration period to each CPT code?	Insert the following options: Yes No
3	Is the volume determined based on an analysis of claims data from the MMIS?	Insert the following options: Yes No If Yes is selected, insert the following option: If Yes, please describe the analysis. Insert Text Box If No is selected, insert the following option: If No, please describe the analysis. Insert Text Box
Section V: Medicare cost comparison is verified as described below:
1	What is the source of the UPL Medicare equivalent data (200-level series variables in the template)?	Insert the following options: State Developed Cost Report using Medicare Cost Identification Principles Modified Medicare Federally Qualified Health Center (FQHC) Cost Report Template (CMS 222) When user selects option 1 display sub-sections “State Developed Cost Report”, “Direct Cost Finding Methodology”, and “Charge Ratio Methodology”. When the user selects option 2 display sub-section “Medicare FQHC Cost Report” section.
State Developed Cost Report (Sub-section)
1	Does the cost report recognize allowable and non-allowable costs in accordance with Medicare Reimbursement Principles (PRM-15-1) and 45 CFR 75?	Insert the following options: Yes No
2	Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?	Insert the following options: Yes No
3	Do providers submit the cost reports to the State Medicaid agency annually?	Insert the following options: Yes No If No is selected, insert the following options: If No, please describe the submission period. Insert Text Box
4	Is the cost report audited by the state agency or through an independent audit?	Insert the following options: Yes No If Yes is selected, insert the following options: If Yes, what is the frequency of the audit? Insert Text Box
Direct Cost Finding Methodology (Sub-section)
1	Does the cost report identify costs directly for Medicaid allowable service cost using an allocation methodology?	Insert the following options: Yes No
2	Please describe the cost identification and allocation process (including the recognized direct costs, treatment of indirect cost, all allocation methods used to determine the costs related to Medicaid services). Note: You may also satisfy this information request by attaching your cost report and cost report instruction.	Insert Text Box
Charge Ratio Methodology (Sub-section)
1	Does the cost report capture all payer cost-to-charge ratios?	Insert the following options: Yes No
2	Does the state apply the Medicaid clinic charges to the cost-to-charge ratios from the same time period as the cost report data?	Insert the following options: Yes No
3	Are the Medicaid charges reported to the MMIS?	Insert the following options: Yes No
4	Please specify the time period of the data used in the state’s cost report.	Insert Text Box
Medicare FQHC Cost Report (Sub-section)
1	Does the provider submit FQHC-based cost reports annually to the state?	Insert the following options: Yes No If No is selected, insert the following options: If No, what is the reporting period? Insert Text Box
2	Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?	Insert the following options: Yes No
3	Does the state capture the same types of allowable costs as reported on the Medicare FQHC cost report?	Insert the following options: Yes No If No is selected, insert the following options: If No, has the state documented and explained the cost category discrepancies? Insert Text Box
4	Please explain all discrepancies and modifications to the FQHC cost report.	Insert Text Box
5	Please specify the time period of the data used in the FQHC cost report.	Insert Text Box
Section VI: Source of the Medicaid Payment Data
1	Are Medicaid base payment data reported from the MMIS?	Insert the following options: Yes No If No is selected, insert the following options: If No, please explain. Insert Text Box
2	Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data and/or the clinic cost reporting period?	Insert the following options: Yes No If No is selected, insert the following options: If No, please explain. Insert Text Box
3	Does the Medicaid payment data include ALL base and supplemental payments to clinic providers? Note: Base and supplemental payments must be separately identified. Any reimbursement paid outside of the MMIS should be included.	Insert the following options: Yes No If No is selected, insert the following options: If No, please explain payments that are made outside of the MMIS. Insert Text Box
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
5	Is the Medicaid payment reported gross or net of primary care payments, deductibles and co-pays?	Insert the following options: Gross Net
6	Describe how Medicaid payment rate changes between the base period and the UPL period are accounted for in the demonstration. For example, a SPA is approved between the base period data and the UPL demonstration period and it increased Medicaid payment rates. The state needs to account for the payment rate change because it is not represented in the base period data. Instructions: In order to account for rate increases or decreases through the approval of a state plan amendment(s), a state will use variable 308 (Medicaid Inflation Factor), 309 (Other Adjustment to MCD Payments), or 408 (Adjustment to the UPL Gap) in the OMB-Approved Template. If the rate increase (or decrease) was implemented as a percentage of the prevailing rate at the time then the state should capture that percentage in either variable 308 or 309. The state has the option to include the increase or decrease in variable 308 along with an inflationary increase the state used to demonstrate the UPL or may include it in variable 309 apart from any inflationary increase. As well, if the rate increase or decrease was not implemented as a percentage change but as a specified amount for each provider then the state may show this in the OMB-Approved Template as specific amounts distributed across all facilities as appropriate in variable 408.	Insert Text Box
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 If 'No' is selected, insert the following question: Please list each SPA number with a brief description of the adjustment. Insert Text box
Section VII: 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 options: If Yes, please explain the trending factor and its source (variable 404 - description). Insert 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
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 clinic services provided in the rate year? How it is applied? Discuss how it is applied consistently to the Medicare equivalent and Medicaid payment data. Insert Text Box
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 options: If Yes, please explain all additional trends or factors for the UPL. Insert 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 data?	Insert the following options: Yes No If Yes is selected, insert the following options: If Yes, please explain the claims completion factor and its application. Insert 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, proceed to question 5a:
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
Section VIII: The state meets clinic UPL demonstration requirements, as below:
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
2	Does the demonstration include all clinic facilities that receive payments under Medicaid?	Insert the following options: Yes No
3	Does the demonstration only includes in-state clinics?	Insert the following options: Yes No If "No" is selected, insert the following question: If No, the clinics should be included in the "private" provider category. The state should also verify that cost/payment data are obtained from the cost reports of the out-of-state clinics. Out-of-state clinics are included in the "private" provider category. Cost and payment data are obtained from the cost report of the out-of-state clinics.

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Sheet 5: Physician

No.	UPL Guidance Question	Response or Follow-Up Questions
Section I: UPL Demonstration Overview:
1	Are there any significant changes to the prior UPL methodology?	Insert the following options: Yes No If 'Yes' is selected, insert the following question: If Yes, please explain. Insert 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.
3	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
4	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
5	Has the provider count changed from the previous UPL demonstration?	Insert the following options: Yes No If 'Yes' is selected, proceed to question 5a.
5a	Please explain the changes, including any new providers, closed providers, or mergers. Please also cite the source of this data.	Insert Text Box
Section II: Type of Demonstration and Payment Methodology
1	Which type of demonstration is used to demonstrate the enhanced payments?	Average Commercial Rate Medicare Equivalent of the Average Commercial Rate If more than one demonstration type is selected, explain which providers receive each kind of payment. (Note: If only one demonstration type is selected then enter "not applicable"). Insert Text Box If user selects ACR then display question 2 If user selects Medicare Equivalent of the ACR then display question 3
2	Indicate the payment methodology for the enhanced payments (Average Commercial Rate)	Alternative Fee Schedule Supplemental payments to the base rates If the user selects Alternate Fee Schedule then display the following question: 2a. Indicate the percentage of the Average Commercial Rate (ACR) that is paid (up to 100%) using the Alternative Fee Schedule Insert Text box If the user selects Supplemental payments to the baser rates then display the following questions: 2b. Indicate the percentage of the Average Commercial Rate (ACR) that is paid (up to 100%) using Supplemental Payments to the base rates Insert Text Box 2c. Describe the base payment methodology for which the supplemental payments are attributed Insert Text box
3	Indicate the payment methodology for the enhanced payments (Medicare Equivalent of the Average Commercial Rate)	Alternative Fee Schedule Supplemental payments to the base rates If the user selects Alternate Fee Schedule then display the following question: 3a. Indicate the Medicare Equivalent of the Average Commercial Rate percentage that is paid using the Alternative Fee Schedule. Insert Text box If the user selects Supplemental payments to the baser rates then display the following questions: 3b. Indicate the Medicare Equivalent of the Average Commercial Rate percentage that is paid using Supplemental Payments to the base rates. Insert Text Box 3c. Describe the base payment methodology for which the supplemental payments are attributed. Insert Text box
Section III. Data Requirements
Information about Payers (Sub-section)
1	Select from the following options:	Insert the following options: The ACR or Medicare Equivalent of the ACR demonstration includes the top (generally five) commercial payers. The ACR or Medicare Equivalent of the ACR demonstration includes all commercial payers.
2	Are the third-party payer data derived from the billing systems of the providers eligible for the enhanced payment?	Insert the following options: Yes No
Payment Data (Sub-section)
1	Do the payments include all copayments and deductibles? The amount of allowed payment by the third party payers includes payment and any patient liability that together equal the total payment for a service allowed by a commercial payer. Note: States must be able to clearly demonstrate how the allowed payment amount was determined under each of the accounts receivable systems of the eligible providers.	Insert the following options: Yes No If No is selected, insert the following question: If No, please explain. Insert Text Box
2	When an enhanced payment is made, is the payment data included for each CPT code provided by the groups of eligible practitioners?	Insert the following options: Yes No If No is selected, insert the following question: If No, please explain. Insert Text Box
Authorized Codes, Dates of Service, and MMIS Data (Sub-Section)
1	Please confirm that the supplemental payment is made only for codes for which base payments are made and that the ACR demonstration includes only those same codes. Codes that do not receive base payments cannot be included in the ACR demonstration and therefore cannot receive supplemental or enhanced payment.	Insert confirmation/verification check box
2	What are the dates of service of the commercial data used in the demonstration?	Dates of Service: Insert Text Box
3	What are the dates of the Medicaid payment and volume data used in the demonstration?	Dates of Service: Insert Text Box
4	Do the dates of service in the commercial payment data match the dates of service for the Medicaid payment/volume data from MMIS? For supplemental/enhanced payments made for time periods that are after the date of the ACR calculation, states must use commercial payment data that is no more than two years old to calculate the ACR. Note: For supplemental/enhanced payments that are made for concurrent ACR demonstration time periods, dates of service in the commercial payment data must match the dates of service included in the Medicaid payment/volume from MMIS.	Insert the following options: Yes No If No is selected, insert the following question: If No, please explain. Insert Text Box
5	Is primary commercial payment source information, such as a payment invoice, provided for at least one billing code, showing how the ACR was calculated?	Insert the following options: Yes No If Yes is selected, insert the following question: If Yes, please list the billing code or codes provided. Insert Text Box
6	Are the Medicaid payment and volume data derived from the MMIS? Note: Using MMIS helps to assure that Medicaid payment has been adjusted for dual eligible liabilities and that payment is associated with covered services delivered to Medicaid beneficiaries.	Insert the following options: Yes No If No is selected, insert the following question: If No, please describe the different source from which Medicaid payment and volume data are derived. Insert Text Box
Payers not Subject to Market Forces and Managed Care (Sub-section)
1	Are FQHCs, RHCs, Medicare, Workers Compensation, and other payers’ data that are not subject to market forces excluded from the demonstration?	Insert the following options: Yes No
2	Are managed care payments made on a capitation or sub-capitation basis excluded?	Insert the following options: Yes No
3	Are managed care entity fee for service payments included?	Insert the following options: Yes No If Yes is selected, insert the following question: If Yes, please explain which services are paid on a fee for service basis, which managed care entities’ data are included, and identify the state plan authority and location for these payments. Insert Text Box
Dually Eligible Beneficiaries (Sub-section)
1	Do the enhanced payments and data exclude services provided to beneficiaries who are dually eligible for Medicaid and Medicare?	Insert the following options: Yes No If No is selected, insert the following question: If No, please document the authority provided in Supplement 1 to Attachment 4.19-B in the following text box Note: Supplement 1 to Attachment 4.19-B of the state plan describes the payment methodology for Medicare Part A and Part B deductibles and co-insurance, as well as any instances of payment for services that are not covered by Medicare. If authorized by the state plan, in these limited circumstances Medicaid may become the primary payer of services and in these cases these data may be included in the calculation of the enhanced payments. If the state plan does not authorize payment for services not covered by Medicare, these data must be excluded from the calculation of enhanced payment. Insert Text Box
2	Describe how payments and charges for which Medicaid is the primary payer are identified.	Insert Text Box
Eligible Providers and Practitioners (Sub-section)
1	List all providers eligible for enhanced payment by campus, geographic location, or some other criteria. This list will identify all academic medical centers, hospitals, and/or other providers that will participate in the enhanced payment.	Insert Text Box
2	Does the demonstration include separate provider-specific ACR calculations or does it calculate only one ACR that includes all providers of these provider-specific payments? Note: If the state is paying providers up to a provider-specific average commercial rate, the demonstration must include separate calculations for each of the providers eligible to receive the enhanced/supplemental payment.	Insert the following options: Separate Provider-Specific ACR Calculations One ACR Calculation that Includes All Providers
3	Are enhanced payments made to non-physicians practitioners?	Insert the following options: Yes No If Yes is selected, insert the following question: If Yes, please list all eligible provider types. Insert Text Box
4	Are data included in the demonstration for all of the types of practitioners whose services are eligible for the enhanced/supplemental payment? Note: In order for a provider to receive enhanced/supplemental payments, the state must provide commercial and Medicaid data for that provider.	Insert the following options: Yes No
5	Are supplemental payments made for providers working under the supervision of a physician? Note: Under 42 CFR 440.50(a) physician services are defined as services furnished by a physician (1) within the scope of practice or medicine or osteopathy as defined by State law; and by or under the personal supervision of an individual licensed under State law to practice medicine or osteopathy. Therefore, the services by providers working under the supervision of a physician, such as nurse practitioners and physicians’ assistants may be paid at the enhanced rate or supplemental ACR payment.	Insert the following options: Yes No
6	Are supplemental payments made for non-physician practitioners? Note: The services of non-physician practitioners, which may include practitioners who are enrolled, qualified Medicaid providers can be targeted for increased payment, subject to an ACR demonstration.	Insert the following options: Yes No
7	Are non-professional services excluded from the data?	Insert the following options: Yes No
8	Please describe how the services of all providers that are eligible for the enhanced/supplemental payment were identified.	Insert Text Box
Radiology, Clinical Diagnostic Laboratories, and Anesthesia Services (Sub-section)
1	Does the demonstration exclude the technical component of radiology services? Note: Radiology services as found in the 70000 CPT series can include both a professional and non-professional, or a technical component that may be paid either separately or through a bundled rate. The technical component is meant to pay for materials used to perform a radiology procedure and is denoted in the billing code with a “TC” modifier. The professional component recognizes physician work associated with reading radiology films. Only the professional component of radiology services should be included in the demonstration if an enhanced payment is made for radiology services.	Insert the following options: Yes No
2	Are any clinical diagnostic laboratory (CDL) services included in the demonstration?	Insert the following options: Yes No If the user selects "Yes" for this question then questions 2a and 2b should be made available. If the user selects "No" then do not ask 2a and 2b.
2a	Are payments for these services made at or below the Medicare rate on a per test basis, as required by section 1903(i)(7) of the Social Security Act? Note: Clinical diagnostic laboratory services as found in the 80000 CPT coding series are mostly non-physician services and are subject to an upper payment limit at section 1903(i)(7) of the Act. The upper payment is limited to the amount Medicare would pay on a per test basis or, a per code basis for a bundled/panel of tests.	Insert the following options: Yes No
2b	Please list any CDL codes that have been included in the demonstration.	Insert Text Box
3	Please explain if the Medicaid payment for anesthesia services directly crosswalks to Medicare payment. In the explanation also indicate if the Medicaid payments are made using the same units of service for time increments as Medicare. If Medicaid does not directly crosswalk to Medicare, please explain how the methodology addresses any differences between the Medicare and Medicaid services. Note: Medicare (and other third party providers) reimburses providers a base amount for each service/CPT Code in addition to an incremental amount for the amount of time used to deliver the service. CMS has found that States do not necessarily measure time in the same way that Medicare does, which is by 15-minute unit. Additionally, if the State included services of CRNA’s (certified registered nurse anesthetists) or other non-physicians rendering anesthesia, those services will be denoted by CPT Codes with modifier “QX” and are usually reimbursed by both commercial payers and Medicaid at a percentage of the fee paid to physicians.	Insert Text Box
Section IV: Steps in Calculating Payment Ceiling using the ACR The average commercial rate (ACR) is used to establish a payment ceiling for supplemental payments to qualified, enrolled Medicaid practitioners. In order for CMS to evaluate if these payments comport with section 1902(a)(30(A) of the Act, which specifies that payments must be efficient and economic, states should submit, in spreadsheet form, a detailed calculation of the average commercial rate (ACR) or the Medicare equivalent of the ACR for all procedure codes eligible for payment to demonstrate how the upper limit of payment was established for practitioner supplemental payments. In addition, states should submit a copy of the invoice which accompanies payment from one of the top commercial payers to document how it identified the allowed amount for at least one code included in the demonstration. The names of the commercial payer(s) on the invoice as well as the spreadsheet detailing the commercial payments can be masked to hide the identity of the payers. States must, however, disclose the names of the commercial payers included in the calculation of the ACR. The steps below describe the methodology that states can use to calculate the ACR to establish an upper payment ceiling for practitioner supplemental payments.
Step 1: Compute the Average Commercial Rate Calculate the average commercial rate per procedure code from the allowed payment amount from each eligible provider’s billing system for the top (generally five), or for all, commercial third party payers (TPP) for the base period. Please see the narrative for further explanation and instructions in calculating the ACR per procedure.
1	Please indicate the name of the spreadsheet submitted to document the detailed calculation of the ACR.	Insert Text Box
Step 2: Calculate the Payment Ceiling a. Multiply the average commercial rate as determined in Step 1 by the number of claims recorded in MMIS for each procedure code that was rendered to Medicaid beneficiaries by eligible practitioners during the base period used for Step 1. b. Add the product for all procedure codes. This total represents the supplemental/enhanced payment ceiling. Note, if enhanced payment is made on a per code basis, the payment ceiling will be a per code ceiling that equals the product of the ACR and the Medicaid volume for that code.
1	Has a payment ceiling been calculated for all practitioners eligible for enhanced/supplemental payment?	Insert the following options: Yes No
2	How is the supplemental/enhanced payment made? Note: Any supplemental or enhanced payment can only be made up to a maximum of the payment ceiling less Medicaid payment in total from MMIS.	Insert the following options: The supplemental/enhanced payment is made on a per code payment ceiling basis The supplemental/enhanced payment is made on the aggregate payment ceiling (the sum of all per code payment ceilings)
3	Were practitioner supplemental/enhanced payments the net of MMIS payments for the eligible codes paid to eligible practitioners?	Insert the following options: Yes No
4	Please indicate the date of the last ACR payment ceiling calculation. Note: If the ACR is used to determine practitioner supplemental payment, the ACR payment ceiling must be calculated annually.	Insert Text Box
Section V: Medicare Equivalent of the Average Commercial Rate Demonstrations States may make supplemental/enhanced payments using the Medicare equivalent of the average commercial rate (ACR). This methodology establishes a ratio of commercial payment to Medicare payment to calculate the supplemental/enhanced payment. This ratio is a single statistic that is multiplied by the Medicare payment for all procedure codes eligible for supplemental payment. The supplemental payment ceiling equals the enhanced payment amount multiplied by the Medicaid volume incurred for each eligible procedure code. The steps below describe the methodology that states can use to calculate the Medicare equivalent of the ACR to establish an upper payment ceiling for practitioner supplemental payments.
Step 1: Calculate the Average Commercial Rate Calculate the average commercial rate per procedure code from the allowed payment amount from each eligible provider’s billing system for the top (generally five), or for all, commercial third party payers (TPPs) for the base period. Please see Step 1 of the narrative section for ACR demonstrations for further explanation and instructions in calculating the ACR per procedure.
1	Please indicate the name of the spreadsheet(s) submitted to document the detailed calculation of the ACR for the procedure codes, by eligible provider, for which supplemental payment will be made.	Insert Text Box
Step 2: Calculate the Medicaid Payment Ceiling An aggregate Medicaid payment ceiling must be calculated. For each of the billing codes for which practitioner supplemental payments are to be made, the ACR for each code is multiplied by Medicaid volume to calculate the amount that would have been paid using the average commercial rate. The resulting amount is the payment ceiling per code; the total payment ceiling is calculated by summing the product of all codes per provider for the codes for which supplemental payment is to be made. Multiply the average commercial rate as determined in Step 1 by the number of claims recorded in MMIS for the same time period as the ACR, per eligible practitioner for each procedure code that was rendered to Medicaid beneficiaries. Sum the product of all procedure codes by provider to calculate the aggregate Medicaid payment ceiling.
1	Has the Medicaid payment ceiling been calculated for each procedure code for which enhanced payment is to be made for eligible Medicaid practitioners?	Insert the following options: Yes No
2	Has the total aggregate Medicaid payment ceiling been calculated for each eligible Medicaid practitioner?	Insert the following options: Yes No
Step 3: Calculate the Average Commercial Rate as a Percentage of Medicare Multiply the Medicare rate per procedure code by the number of claims recorded in MMIS for each procedure code that was rendered to Medicaid beneficiaries during the base period used for Step 1. Add the product for all procedure codes; this sum represents total Medicare payment that would have been received. Divide the total Medicaid payment ceiling by total Medicare payments. This single statistic expresses the ACR as a percentage of Medicare and will be used to calculate enhanced Medicare payment rates for determining supplemental payments (Step 4). The Medicare fee schedule used for the calculation of the Medicare equivalent of the ACR single statistic must be specified in the state plan. In addition, only Medicare fees for procedures that are authorized by the Medicaid state plan can be included in the calculations.
1	Are all Medicaid services matched to Medicare services by CPT/billing code?	Insert the following options: Yes No
2	Please confirm that the Medicare Physician Fee Schedule is from the same time period as the rates obtained from the commercial payers, the Medicaid rates and the Medicaid services provided.	Insert confirmation/verification check box
3	Please indicate the RVUs issued by Medicare as of:	Date: Insert Text Box
4	Do RVUs vary by site of service?	Insert the following options: Yes No
5	Are facility RVUs used?	Insert the following options: Yes No
6	Are non-facility RVUs used?	Insert the following options: Yes No
7	Do the RVUs vary by geographic locale as defined by Medicare?	Insert the following options: Yes No
8	Does the state update its methodology within a single rate year?	Insert the following options: Yes No
Step 4: Calculate Total Maximum Supplemental Payment The total maximum supplemental payment per provider is calculated by multiplying the Medicare equivalent of the ACR (the single statistic) by the Medicare rate for each eligible procedure code, summing the product of each code, and subtracting MMIS payments per eligible procedure code for which supplemental payment is to be made. The total supplemental payment for each eligible provider can be made only up to this net amount. Enhanced payment can be made on a per code basis, which would be equal to the single statistic multiplied by the Medicare rate per code. If this payment methodology is used, all base Medicaid payments must be subtracted for each procedure code to determine the maximum supplemental payment amount that can be made for that code.
1	Is the Medicare equivalent of the ACR multiplied by the Medicare rate for all eligible codes for procedures reported in MMIS?	Insert the following options: Yes No
2	Is the volume of eligible procedure codes reported from MMIS claims per eligible practitioner?	Insert the following options: Yes No
3	Is the maximum supplemental payment per eligible practitioner equal to, or less than, the Medicaid payment ceiling per practitioner, respectively?	Insert the following options: Yes No
4	Have paid claims from MMIS for the same time period as the volume reported for each eligible practitioner been subtracted from the sum of the enhanced payment rate multiplied by volume per provider?	Insert the following options: Yes No
5	How are supplemental/enhanced payments made?	Insert the following options: Payments are made per code, rather than as an aggregate amount equal to the sum of the enhanced payment per code Payments are made based on the aggregate amount, or sum, of all eligible procedure codes
6	Is the total net supplemental payment (enhanced payment less Medicaid payment) reported per eligible practitioner?	Insert the following options: Yes No
7	Are supplemental payments at or below the maximum net supplemental payments as calculated per eligible practitioner? Note: Any supplemental or enhanced payment can only be made up to a maximum of the payment ceiling less Medicaid payment in total from MMIS (net supplemental payments) for each eligible provider.	Insert the following options: Yes No