Frequently Asked Questions

The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.

FAQ ID:92231

The submission package consists of the completed templates and any supporting documentation needed to understand the UPL demonstration. This could include the completed Guidance document and supporting documentation (in Microsoft Excel with formulas included, not as a PDF) that is necessary to further explain a state's UPL demonstration, and a summary spreadsheet that aggregates the UPL gap for each of the ownership categories (state government owned, non-state government owned, and private).

FAQ ID:92236

Yes, a state should submit multiple workbooks to CMS to provide a complete UPL demonstration for each service category subject to the UPL (Inpatient Hospital services (IPH), Outpatient Hospital services (OPH), Nursing Facility services (NF), Clinic, Institutions for Mental Disease (IMD), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Psychiatric Residential Treatment Facility (PRTF), and Qualified Practitioner supplemental payments). When submitting UPL demonstrations, the state should 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.As well, states may submit one separate workbook for each ownership category (state government owned, non-state government owned, and private).

FAQ ID:92241

No, the information must be submitted by the State Medicaid Director (or designated state official).

FAQ ID:92246

States are requested to submit their UPL demonstrations to the UPL mailbox at MedicaidUPL@cms.hhs.gov, but should also send a copy of each demonstration to their CMS Regional Office, including the National Institutional Reimbursement Team (NIRT) and Non-Institutional Payment Team (NIPT) staff as appropriate, and addressed to the Associate Regional Administrator. UPL demonstrations should be submitted to meet the annual reporting requirement described in SMDL 13-003, as well as when proposing changes in payment through SPAs.

FAQ ID:92251

The Regional Office will continue to review state UPL demonstrations and states will continue to work with the CMS Regional Offices as a first point of contact concerning their UPL demonstrations.

FAQ ID:92256

CMS plans to provide technical assistance on transition plans to States through the State Operations and Technical Assistance Team (SOTA) calls and through other calls with the State. We will also be providing additional guidance about the information that should be included in the transition plans. We will consider the transition plans that need to be submitted by the due date as living documents that are open to revision, and will continue to work with States to ensure a seamless transition in 2014 for beneficiaries and States.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 55.99 KB)

FAQ ID:93021

The Affordable Care Act provides significant federal support to ensure the availability of coverage to low-income adults. Enrollment caps limit enrollment in coverage on a first come, first serve basis. Periods of ineligibility delay or deny coverage for otherwise eligible individuals. These policies do not further the objectives of the Medicaid program, which is the statutory requirement for allowing section 1115 demonstrations. As such, we do not anticipate that we would authorize enrollment caps or similar policies through section 1115 demonstrations for the new adult group or similar populations.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93751

Demonstrations focused on changes to how health care services are delivered, such as the use of managed care, will not generally affect the state's matching rate. Please refer to our February 2013 FAQs (PDF, 135.35 KB), which provide further clarification on the two increased federal match rates: the newly eligible rate and the expansion state rate as well as the final FMAP rule published on April 2, 2013. Additionally, CMS issued two State Medicaid Director letters, on July 10, 2012, that provide guidance on how states can adopt integrated care models without the need for a section 1115 demonstration.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 105.59 KB)

FAQ ID:93756

Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 41.01 KB)

FAQ ID:94276