ICF/IID Upper Payment Limit (UPL) Supplemental Payment Program

General Information

The Texas Health and Human Services Commission (HHSC) implemented an Upper Payment Limit (UPL) Supplemental Payment Program in 2014 for non-state government-owned Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID). Eligibility for participating in the program, and the methodology for calculating the supplemental payment amount, is governed by Title 1 of the Texas Administrative Code (TAC) §355.458.

Participation in this program is voluntary and is limited to non-state government-owned ICF/IID facilities. A non-state government-owned ICF/IID facility is defined as an ICF/IID facility where a non-state governmental entity is party to the facility's Medicaid contract. A non-state governmental entity is defined as a hospital authority, hospital district, healthcare district, city, or county.

Federal regulations at Title 42 Code of Federal Regulations 447.272 allow states to claim federal matching funds under Medicaid up to what Medicare would pay for a similar service. Under this UPL supplemental program, a participating non-state government entity would contribute the "state share" of the supplemental payment in the form of Inter-Governmental Transfers (IGTs). The state will claim matching funds and will make a supplemental payment to the ICF/IID facility based on the supplemental amount calculated by the state and the IGT amount transferred by the entity.

Participation Documents

To participate in the first quarter of the UPL Supplemental Payment program for the current federal fiscal year, eligible facilities must complete a Certification Form and return it to the Rate Analysis Department at the address below no later than January 13, 2020. Certification Forms received after January 13, 2020 or Certification Forms that are incorrectly completed as of this date, may not participate in the first quarter of the UPL Supplemental Payment. The Certification Form must be signed by a person who is legally authorized to bind the facility and to certify these matters, and the form must be notarized. Participation is voluntary.

Deadlines for HHSC receipt of the Certification forms:

FFY Quarter Participation Starting Date Submission Deadline
1st Quarter October 1, 2019 January 13, 2020
2nd Quarter January 1, 2020 February 21, 2020
3rd Quarter April 1, 2020 March 31, 2020
4th Quarter July 1, 2020 June 30, 2020

If the ownership of the facility is in the process of being changed and the facility will become a non-state government-owned facility, submit the certification form by the deadline pending the change of ownership.

View an electronic version of the certification form

Send completed, notarized Certification Forms to the following.

Regular Mail Overnight Courier Special Delivery
Attn: Joseph Melendez Attn: Joseph Melendez
HHSC Rate Analysis HHSC Rate Analysis
Mail Code H-400 Brown Heatly Building, Mail Code H-400
P.O. Box 149030 4900 N. Lamar Blvd.
Austin, TX 78714-9030 Austin, TX 78751-2399

The UPL program year coincides with the Federal Fiscal Year. Payments to a participating ICF/IID facility will be calculated based on Medicaid units of service attributable to each federal fiscal quarter. The first quarter for which payments will be calculated is October 1, 2019 through December 31, 2019. The amount of the first quarter's payment will be determined in January 2020 and it is imperative that the facility complete the billing for the first quarter prior to January 2020. Payments for the first quarter are anticipated to be distributed in February 2020. The amount of the fourth quarter's payment will be determined after the first three quarters' payments have been made and are dependent on whether or not the facility transferred the maximum IGT amount in each of the first three quarters.