Upper Payment Limit FAQs

The difference between a prospective and retrospective UPL is in the relationship between the UPL demonstration period and the date when the UPL is submitted. For a UPL demonstration period of 7/1/2018 to 6/30/2019, a UPL is considered retrospective when it is submitted on or after the start of the demonstration period (on or after 7/1/2018). Using the same UPL demonstration period (7/1/2018 to 6/30/2019), a UPL is considered prospective if it is submitted prior to 7/1/2018.

Yes, a demonstration submitted within the fiscal year that is used to document that SPA methodology changes comply with the UPL requirements may be used to satisfy the SMDL requirements as long as no subsequent changes are made to the state's provider payment methodology prior to the state's annual submission and CMS has reviewed and accepted the demonstration.