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1
Clinic Upper Payment Limit (UPL) Guidance
I. Services are subject to the clinic UPL as described below:
☐
☐
☐
Covered and paid under the clinic benefit in the state plan, and
Provided by freestanding clinics (i.e. excludes: provider-based entities, Federally Qualified
Health Clinics, FQHC look-alikes or rural health clinics)
Other (please describe below)
This demonstration description applies to:
☐
☐
All Medicaid freestanding clinics
The Medicaid freestanding clinic type(s) described below:
State clinic service payment methodology for the services:
Does the state pay a Medicaid rate for all services provided by the clinic?
☐
☐
Yes
No
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?
☐
☐
Yes
No
If yes, state the percentage: ______
Does the state pay clinics using an encounter rate?
☐
☐
Yes
No
2
If yes, does the state track by CPT or other billing code the individual services that Medicaid
beneficiaries actually receive?
☐
☐
Yes
No
If no, please explain.
Demonstration comprehensiveness:
Are all of the Medicaid clinic services provided by the providers listed above accounted for in
the demonstration?
☐
☐
Yes
No
If no, please explain.
II. The basis of the UPL formula is:
☐ State payment rate schedule to Medicare RBRVS Comparison Demonstration (Medicare
non-facility fee schedule per CPT)
☐
☐
Medicaid Cost Demonstration
Other (please describe below):
What is the time period of the data, including the beginning and ending dates?
Base year data: _______
Rate year data: _______
3
Is the data the most recently available to the state?
☐
☐
Yes
No
III. Medicare payment comparison is verified as described below:
The source of the UPL Medicare equivalent data is:
☐ Medicare Fee Schedule
Is the Medicare fee schedule for the same time period as the Medicaid payment data?
☐
☐
Yes
No
What is the date of the Medicare fee schedule that is used in the demonstration?: _________
☐ Other Data Source (please describe below):
Identification of Medicare Equivalent Codes:
Are all Medicaid services linked to a Medicare-equivalent CPT code?
☐
☐
Yes
No
If no, please explain and provide a crosswalk between CPT and local codes.
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?
☐
☐
Yes
No
4
If yes, please explain the Medicare codes, or equivalent codes, used in the demonstration
and the equivalent Medicaid payment.
Does the state apply Medicaid volume of service rendered within the demonstration period to
each CPT code?
☐
☐
Yes
No
Is the volume determined based on an analysis of claims data from the MMIS?
☐
☐
Yes
No
Please describe the analysis:
IV. Medicare cost comparison is verified as described below:
The source of the UPL Medicare equivalent data is:
☐
☐
State Developed Cost Report using Medicare Cost Identification Principles
Modified Medicare Federally Qualified Health Center (FQHC) Cost Report Template (CMS
222)
State developed cost report:
Does the cost report recognize allowable and non-allowable costs in accordance with Medicare
Reimbursement Principles (PRM-15-1) and OMB Circular A-87?
☐
☐
Yes
No
5
Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?
☐
☐
Yes
No
Do providers submit the cost reports to the State Medicaid agency annually?
☐
☐
Yes
No
If no, please describe the submission period: ___________
Is the cost report audited by the state agency or through an independent audit?
☐
☐
Yes
No
If yes, what is the frequency of the audit?
___________
Direct Cost Finding Methodology
Does the cost report identify costs directly for Medicaid allowable service cost using an
allocation methodology?
☐
☐
Yes
No
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). You may also satisfy this information request by attaching
your cost report and cost report instruction.
6
Charge Ratio Methodology
Does the cost report capture all payer cost-to-charge ratios?
☐
☐
Yes
No
Does the state apply the Medicaid clinic charges to the cost-to-charge ratios from the same time
period as the cost report data?
☐
☐
Yes
No
Are the Medicaid charges reported to the MMIS?
☐
☐
Yes
No
Please specify the time period of the data used in the state’s cost report.
_______________
Medicare FQHC Cost Report:
Does the provider submit FQHC-based cost reports annually to the state?
☐
☐
Yes
No
If no, what is the reporting period?
__________________
Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?
☐
☐
Yes
No
7
Does the state capture the same types of allowable costs as reported on the Medicare FQHC cost
report?
☐
☐
Yes
No
If no, has the state documented and explained the cost category discrepancies?
Please explain all discrepancies and modifications to the FQHC template.
Please specify the time period of the data used in the FQHC cost report.
________________________
V. The state UPL data demonstration is structured as follows:
The state conducted the UPL demonstration separately for government owned or operated, non-
state government owned or operated and privately owned or operated clinics.
☐ Yes
☐ No
All Medicaid base and supplemental payments are included in the demonstration and are
separately identified.
☐
☐
Yes
No
The demonstration includes all clinic facilities that receive payments under Medicaid.
☐
☐
Yes
No
8
The demonstration only includes in-state clinics.
☐
☐
Yes
No
If the state includes out-of-state clinics in the UPL calculation, please verify that the data on
cost/payments was obtained from the cost report of the out-of-state clinics and that the clinics are
included in the “private” provider category?
☐
☐
Yes
No
VI. Source of the Medicaid Payment Data
Medicaid base payment data is reported from the MMIS.
☐
☐
Yes
No
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/or the hospital cost reporting period?
☐
☐
Yes
No
If no, please explain:
9
Medicaid payment data includes ALL base and supplemental payments to clinic 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 excludes crossover claims.
☐ Yes
☐ No
Is the Medicaid payment reported gross or net of primary care payments, deductibles and co-
pays?
☐
☐
Gross
Net
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?
10
VII. The state trends and adjusts the UPL Data, as below:
Does the state trend 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
Does the state trend the UPL for volume/utilization?
☐
☐
Yes
No
Explain the volume/utilization adjustment, including: how it will assure the UPL does not
over or understate the volume of Medicaid inpatient clinic 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:
11
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
VIII. The state meets clinic UPL demonstration requirements, as below:
The state has submitted supporting spreadsheet data to CMS, by provider, that demonstrates:
The state under the UPL in the aggregate for state-owned clinics.
☐
☐
Yes
No
The state under the UPL in the aggregate for non-state-owned clinics.
☐
☐
Yes
No
12
The state under the UPL in the aggregate for private clinics.
☐
☐
Yes
No
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Completed 7 December 2019

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