Frequently Asked Questions

Medicaid and the Children’s Health Insurance Program (CHIP) can reimburse states for expenditures incurred by Local Education Agencies (LEAs)/school districts for the costs of administrative activities that support the provision of medical services covered under Medicaid or CHIP. Examples of allowable Medicaid and CHIP administrative activities can be found on page 75 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming. In general, some categories where administrative activities can fall include:

• Medicaid and CHIP outreach.
• Facilitating Medicaid and CHIP eligibility determinations.
• Transportation-related activities in support of Medicaid and CHIP services.
  • Note, when the State claims federal financial participation (FFP) for necessary transportation as an optional medical service, the State must not also claim the same transportation expenditures as an administrative activity, which would result in duplicative reimbursement.
• Translation and interpretation services related to covered services.
• Program planning, policy development, and interagency coordination related to Medicaid and CHIP.
• Medicaid- and CHIP-related training.
• Referral, coordination, and monitoring of Medicaid and CHIP services (distinct from case management activities covered as a medical service).

FAQ ID:162306

Yes, States are expected to apply the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming guidance to all MAC programs for all entities. Both previous guidance documents issued by CMS, including the 1997 School-based Services Technical Review Guide and the 2003 School-based Administrative Claiming Guide, are superseded by the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming.

FAQ ID:162336

First, the activities must be allowable as State program administrative activities. Secondly, the State and/or claiming unit must implement a methodology to properly identify and allocate Medicaid’s portion of cost associated with the allowable State program administrative activity. Finally, the identification and allocation of this cost must be documented in the State’s Public Assistance Cost Allocation Plan (PACAP). According to 45 C.F.R. § 95.517, State Medicaid agencies (SMAs) that intend to claim for allowable administrative activities must have an approved PACAP. As the PACAP is primarily used by the Federal cognizant agency to allocate cost incurred by one direct federal awardee, yet funded by another federal awardee, there may be instances where costs applicable to allowable State program activities are incurred and funded by the SMA. In this instance, the State may identify and allocate the cost via a Medicaid Administrative Claiming (MAC) Plan and include a reference to the identification and allocation of the cost via the MAC Plan in its PACAP.

FAQ ID:162321

CMS encourages SMAs to reimburse school districts their allowable costs of conducting Medicaid and CHIP administrative activities. School districts should work with SMAs to develop a plan to document their costs so that the SMA can distribute Medicaid and CHIP FFP to school districts in proportion to each district’s relative expenditures for Medicaid and CHIP administrative activities.

FAQ ID:162326

In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.

FAQ ID:92446

Effective state fiscal year 2020, each state must submit a complete data set of payments to Medicaid providers, including providers paid at cost, as well as critical access hospitals. This would require states to submit cost and payment data to CMS that previously was not requested.

FAQ ID:92456

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.

FAQ ID:92431

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

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

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