Nursing Facility Upper Payment Limit (UPL) Supplemental Payment Program

Overview

The Texas Health and Human Services Commission (HHSC) is implementing a new Upper Payment Limit (UPL) Supplemental Payment Program for non-state government-owned nursing facilities. 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) §355.314.

Participation in this program is voluntary and is limited to non-state government-owned nursing facilities. A non-state government-owned nursing facility is defined as a nursing facility where a non-state governmental entity holds the license and 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 nursing 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, eligible facilities must complete a Certification Form and return it to Rate Analysis Department at the address below no later than September 30, 2013. Certification Forms received after September 30, 2013, 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 - 2014 October 1, 2013 September 30, 2013
2nd Quarter - 2014 January 1, 2014 December 31, 2013
3rd Quarter - 2014 April 1, 2014 March 31, 2014
4th Quarter - 2014 July 1, 2014 June 30, 2014
1st Quarter - 2015 October 1, 2014 September 30, 2014
2nd Quarter - 2015 January 1, 2015 December 31, 2014

If the ownership of the facility is changing 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 (.pdf)

Send completed, notarized Certification Forms to the following.

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

The UPL program year coincides with the Federal Fiscal Year. Payments to a participating nursing facility will be calculated based on Medicaid claims adjudicated during each federal fiscal quarter. The first quarter for which payments will be calculated is October 1, 2013 through December 31, 2013. The amount of the first quarter's payment will be determined in April 2014 and it is imperative that the facility complete the billing for the first quarter prior to April 2014. Payments for the first quarter are anticipated to be distributed in May 2014. 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 amounts in each of the first three quarters.

Training Information

In order to assist you in understanding the requirements of the UPL Supplemental Payment Program enrollment and participation, webinar training sessions were scheduled. These webinar opportunities were optional for enrollment; however, participation in the webinar was recommended. You can review the presentation on-line.

View the webinar PowerPoint presentation - updated 09/20/13