Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
Are states that provide durable medical equipment (DME) through a managed care arrangement required to submit the reconciliation data?
Only those items provided in the Medicaid program on a fee-for-service basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the federal financial participation limitation.
FAQ ID:93541
SHARE URLCenters for Medicare & Medicaid Services is saying this durable medical equipment (DME) limit on federal financial participation is applicable only to fee for service (FFS). How about the Home and Community-Based Services (HCBS) waiver programs?
If the HCBS waiver includes FFS payments for DME, the state’s expenditures for DME would be subject to the limit.
FAQ ID:93546
SHARE URLHow can a state contact the Centers for Medicare & Medicaid Services (CMS) for help with the federal financial participation (FFP) Limit for state expenditures for durable medical equipment (DME)? Where can a state submit statements and supporting evidence that the states are already in compliance with this DME limit on FFP based on the state using Medicare rates?
For technical assistance with the implementation efforts and assistance with determining if current state practices are below the FFP limit, please contact the Medicaid DME mailbox: MedicaidDME@cms.hhs.gov.
FAQ ID:93476
SHARE URLWhere can states find a list of the Medicare competitive bidding areas (CBAs), including zip codes and areas of the state, and how does a state find out if it has CBAs?
States may review Medicare’s CBAs through the following website for the most up-to-date information: www.dmecompetitivebid.com. In the alternative, the Center for Medicaid and CHIP Services (CMCS) has a list of states and CBAs by state that is available upon request. We will monitor the lists and update them with any necessary Medicare changes. As of January 1, 2018, the following states and territories do not have CBAs: Alaska, Maine, Vermont, North Dakota, South Dakota, Montana, Wyoming, and all of the US territories.
FAQ ID:93481
SHARE URLDoes CMS require states to submit their 2019 Upper Payment Limit (UPL) demonstrations using the Office of Management and Budget (OMB) approved templates for Inpatient Hospital services (IPH), Outpatient Hospital services (OPH), and Nursing Facility services (NF) UPLs?
Yes, CMS requires states to use all of the OMB approved templates for their 2019 (07/01/2018 to 06/30/2019) UPL demonstrations submitted to meet the annual UPL reporting requirement and with State Plan Amendment (SPA) submissions. When submitting UPL demonstrations, use the following naming convention: UPL_<UPL Demo Date Range>_<Service Type Abbreviation>_R<Region Number>_<State Abbreviation>_<Workbook Number>.xls. Here is an example of the naming convention: UPL_20170701-20180630_IP_R01_CT_01.xls.
FAQ ID:92196
SHARE URLWhen a state pays at or less than the Medicare rate is it required to submit an Upper Payment Limit (UPL) demonstration using the template(s)?
No, if a state's payment methodology describes payment at no more than 100 percent of the Medicare rate for the period covered by the UPL then it does not need to submit a demonstration using the template(s). To show the state has met the annual UPL demonstration reporting requirement it should make CMS aware that it is paying no more than the Medicare rate.
FAQ ID:92201
SHARE URLIf a state's inpatient hospital, outpatient hospital, or nursing facility Upper Payment Limit (UPL) demonstration has been approved by CMS for demonstration year 2018, does the UPL template still need to be populated and submitted for 2018?
No, states that already have submitted their 2018 (07/01/2017 - 06/30/2018) inpatient hospital, outpatient hospital, or nursing facility services UPL demonstrations will not have to resubmit using the templates. In that instance, CMS will populate the templates using data already submitted by the state.
FAQ ID:92211
SHARE URLCan a state use an Upper Payment Limit (UPL) demonstration that was submitted within the fiscal year for purposes of demonstrating that a State Plan Amendment (SPA) change complies with the regulations in order to meet the State Medicaid Director Letter (SMDL) requirements?
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.
FAQ ID:92216
SHARE URLAre there any circumstances that would allow a state to apply the same Upper Payment Limit (UPL) demonstration to multiple years?
When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.
FAQ ID:92221
SHARE URLShould the period of time covered by the Upper Payment Limit (UPL) demonstration be tied to the state's fiscal year?
No, CMS does not require any particular starting point within the fiscal year for the UPL demonstrations. This allows states the flexibility to develop UPL demonstrations that are tied to the provider payment periods described in the state plan payment methodologies for each service. For instance, if a state submits a state plan amendment to update provider payments as of October 1 of each year, the state would document that the SPA changes comply with the UPL for the period 10/1 - 9/30 of that payment year. The UPL must represent the entire payment year. Since UPL demonstrations usually rely on historic data that is projected into a payment year, this is consistent with past practices.
FAQ ID:92226
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