Fillable Outpatient Hospital Upl Guidance Final Fillable (Centers for Medicare & Medicaid Services)

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Outpatient Hospital Upl Guidance Final Fillable (Centers for Medicare & Medicaid Services)

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1
Outpatient Hospital UPL Guidance
I. The basis of the UPL formula is:
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):
Please provide a general description of the formula:
II. The source of the UPL Medicare equivalent data is:
The Medicare Cost Report (CMS 2552)
Filed or
Settled or
Other Data Source (Please describe)
What is the time period of the data?
Base year data: ________________________
Rate year data: ________________________
III. The state uses the cost report references below:
Cost-Based Demonstration (Cost-to-Charge Ratio):
Worksheet C
Worksheet D
2
Describe which columns and lines that are used to determine the cost-to-charge ratios.
Payment-to-Charge Demonstration (Payment to Charge Ratio):
Worksheet E, Part B (Payments) / Worksheet D, Part V and VI (Charges)
Describe which columns and lines that are used to determine the payment-to-charge ratios.
Does the Medicare payment data represent gross reported payment or are adjustments made to
the data to capture the net payment?
Gross
Net
For net reported payments, please explain the adjustments for primary care 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).
Other Cost Report Worksheets, Columns and Lines used:
If the state uses other worksheets, describe them and how they are applied.
3
IV. The State applies the Medicaid charge data, as described below to the Medicare
charge ratios:
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 data match the dates of services from the
Medicare cost report data? If no, please explain.
Does the state only include Medicaid charges from in-state Medicaid residents?
Yes
No
Does the charge data exclude crossover claims?
Yes
No
Are physicians and other professional services excluded?
Yes
No
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.
V. The UPL demonstration applied Medicaid payment data as follows:
Medicaid base payment data is reported from the MMIS.
Yes
No
4
If the source of the payment data is a different source, please explain:
Are the dates of service for the Medicaid payment data consistent with the Medicaid charge data
and the hospital cost reporting period?
Yes
No
If no, please explain:
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.
Yes
No
Please explain payments that are made outside of the MMIS.
Medicaid payment data exclude crossover claims.
Yes
No
Is the Medicaid payment reported gross or net of primary care payments, deductibles and co-
pays?
Gross
Net
5
Describe how Medicaid payment rate changes between the base period and the UPL period are
accounted for in the demonstration?
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?
Yes
No
If no, please provide a reconciliation and explanation of the difference?
VI. The State trends and adjusts the UPL Data, as below:
The State trends the UPL for inflation
Yes
No
Explain the trending factor and its source.
Is the inflation trend applied from “mid-point to the mid-point” in order to most accurately
project future experience?
Yes
No
The state trends the UPL for volume/utilization
Yes
No
6
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:
Please explain all additional trends or factors that are used in the demonstration and their
application:
Does the state apply a claims completion factor to the payment data?
Yes
No
Please explain the claims completion factor and its application:
Does the state apply a claims completion factor to the charge data?
Yes
No
Please explain the claims completion factor and its application:
Is the claims completion factor equally applied to the payment and charge data?
Yes
No
7
VII. The state has conducted an analysis of clinical diagnostic laboratory services:
The State plan specifies that the State pays a percentage of the Medicare fee schedule for clinical
diagnostic lab services in compliance with section 1903(i) of the Social Security Act?
Yes
No
The State does not pay a percentage of Medicare, however, the State demonstrates that Medicaid
payment rates fall below the Medicare fee schedule for clinical diagnostic lab services on a per
test basis?
Yes
No
The State included clinical diagnostic lab services in the outpatient UPL. The State demonstrates
compliance with section 1903(i) of the Act through a demonstration or assurance that payments
do not exceed the Medicare fee schedule on a per test basis.
Yes
No
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 hospitals.
Yes
No
All Medicaid base and supplemental payments are included in the demonstration and are
separately identified.
Yes
No
The demonstration includes all facilities that receive outpatient hospital payments under
Medicaid.
Yes
No
8
The demonstration only includes in-state hospitals.
Yes
No
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.
Yes
No
Are Critical Access Hospitals included?
Yes
No
Describe how the state accounts for CAHs in the UPL calculation?
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.
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Outpatient Hospital Upl Guidance Final Fillable (Centers for Medicare & Medicaid Services)

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Completed 24 July 2020

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