Upper Payment Limit FAQs

Section 1903(i)(7) of the Social Security Act specifies a separate UPL for CDL services which limits payment to no more than the Medicare rate on a per test basis. To meet the statutory provision, the UPL for CDL services must be separately demonstrated from the OPH services UPL. States do not have the ability to "borrow room" from the CDL UPL and apply it to the OPH UPL.

Yes, a state may choose between using all-payer data or Medicare-specific data from the Medicare Hospital Cost Report (CMS Form 2552) to determine the cost-to-charge ratios.