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Upl-guidance-icfdd-services-final-12-18-13 Clinic Upper Payment Limit (UPL) Guidance

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1
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
I. The basis of the UPL formula is:
☐
☐
Medicaid Cost Demonstration Using Medicare Cost Finding Principles
Other (please describe below):
W
hat is the time period of the data used in the demonstration, including the beginning and ending
dates?
B
ase year data:
_______
_______
R
ate year data:
Is the data the most recently available to the state?
☐
☐
Yes
No
II. 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 Skilled Nursing Facility Cost Report (CMS 2540)
Cost report development:
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
Has the Centers for Medicare and Medicaid Services (CMS) reviewed the cost report?
☐
☐
Yes
No
2
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?
________________
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?
☐
☐
Yes
No
☐ Not applicable
If no, has the state documented and explained the cost category discrepancies?
Please explain all discrepancies and modifications to the SNF template.
Cost Finding Methodology
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).
3
Are indirect/overhead costs and direct service costs separately identified on the cost report?
☐
☐
Yes
No
Are both routine and ancillary service costs identified on the cost report?
☐
☐
Yes
No
Are ancillary service costs separately identified on the cost report?
☐
☐
Yes
No
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/ID cost.
Are Central Office or related entity costs allocated to the ICF/IDs?
☐
☐
Yes
No
Please describe how Central Office or related entity costs are identified in the cost report and are
allocated to represent actual Medicaid incurred cost:
Charge Ratio Methodology (applies to both state-developed cost report and Medicare-based cost
report)
Does the cost report calculate cost-to-charge ratios for defined cost centers to which allowable costs are
allocated?
☐
☐
Yes
No
4
If no, please explain:
D
oes the cost report capture all payer cost-to-charge ratios?
☐
☐
Yes
No
Are the cost-to-charge ratios applied on a facility-wide or cost center-specific basis?
☐
☐
☐
☐
Facility-wide, inclusive of both routine and ancillary cost centers
Facility-wide, but only for ancillary cost centers (routine cost center is on a per diem basis)
Cost center-specific, for each ancillary cost center only (routine cost center is on a per diem basis)
Cost center-sp
ecific, for each ancillary and routine cost center
Does the state apply the Medicaid ICF/ID charges to the cost-to-charge ratios from the same time period
as the cost report data?
☐
☐
Yes
No
Are the Medicaid billed and covered charges reported to the MMIS?
☐
☐
Yes
No
Please specify the time period of the data used in the state’s cost report.
_______________
Application of Medicaid days to per diem cost (applies to both state-developed cost report and
Medicare-based cost report)
Does the cost report arrive at an ICF/ID cost per diem for each facility and apply Medicaid days to the
per diem?
☐
☐
Yes
No
5
For the determination of cost used for the per diem, is cost exclusive or inclusive of cost associated with
non- certified beds?
☐ Exclusive
☐ Inclusive
Has the per diem cost and/or Medicaid rates been adjusted for low occupancy?
☐
☐
Yes
No
Is the per diem ICF/ID cost inclusive of all routine and ancillary services?
☐
☐
Yes
No
Does the state use paid claims data from the MMIS as the source of the Medicaid days?
☐
☐
Yes
No
Are the Medicaid days used in the UPL calculation from the same period as the cost report period?
☐
☐
Yes
No
III. 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 ICF/IDs.
☐
☐
Yes
No
All Medicaid base and supplemental payments are included in the demonstration and are separately
identified.
☐
☐
Yes
No
6
The demonstration includes all ICF/ID facilities that receive payments under Medicaid.
☐
☐
Yes
No
The demonstration only includes in-state ICF/IDs.
☐
☐
Yes
No
If the state includes out-of-state ICF/IDs in the UPL calculation, please verify that the data on
cost/payments was obtained from the cost report of the out-of-state ICF/ID and that the ICF/IDs are
included in the “private” provider category?
☐
☐
Yes
No
IV. 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:
A
re the dates of service for the Medicaid payment data consistent with the Medicaid cost reporting
period?
☐
☐
Yes
No
If no, please explain:
7
Medicaid payment data includes ALL base, add-ons, and supplemental payments to ICF/ID 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.
W
here the state makes Medicaid payment outside of Attachment 4.19-D for other services furnished to
ICF/ID residents, are these Medicaid payments excluded from the UPL demonstration?
☐
☐
Yes
No
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.
M
edicaid 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?
8
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?
9
V.
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.
D
oes the state exclude capital costs from the trending?
☐
☐
Yes
No
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 ICF/ID services provided in the rate year, how it is applied and
that it is applied consistently to the Medicare equivalent (the UPL) and Medicaid payment data:
P
lease explain all additional trends or factors that are used in the demonstration and their
application:
10
Does the state apply a claims completion factor to the payment data?
☐
☐
Yes
No
Please explain the claims completion factor and its application:
D
oes the state apply a claims completion factor to the Medicaid day and/or charge data?
☐
☐
Yes
No
Please explain the claims completion factor and its application:
I
s the claims completion factor equally applied to the payment and Medicaid day and/or charge data?
☐
☐
Yes
No
VI.
The state meets ICF/ID 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 ICF/IDs?
☐
☐
Yes
No
The state under the UPL in the aggregate for non-state-owned ICF/IDs?
☐
☐
Yes
No
11
The state under the UPL in the aggregate for private ICF/IDs?
☐
☐
Yes
No
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Completed 6 December 2019

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