Projects

Upper Payment Limits and Medicaid Disproportionate Share Hospital Payments Analysis & Technical Support

2019-2024

Project Overview

Objective

To support CMS in executing its oversight role over Medicaid payments to providers, including Medicaid Upper Payment Limit (UPL) demonstrations, Disproportionate Share Hospital Payments (DSH), and supplemental payments.

Project Motivation

In order to ensure consistency with the statutory goals of economy and efficiency, CMS seeks to improve its oversight of billions of dollars in fee-for-service base and supplemental Medicaid payments to providers.

Prepared For

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services

Mathematica is providing technical support, technical assistance, and project support to CMS to assist its efforts to ensure Medicaid fee-for-service base and supplemental payments to providers are both economical and efficient.

This project helps CMS exercise oversight over Medicaid fee-for-service base and supplemental payments to providers and ensure that those payments are consistent with regulatory requirements related to efficiency, economy, and access to services. As part of this oversight, states are required to demonstrate to CMS on an annual basis that these provider payments in aggregate are below an Upper Payment Limit (UPL), typically defined as a reasonable estimate of the amount that Medicare would have paid for the same services.

We work closely with CMS to validate all UPL data submitted by states. Examples of project activities include:

  • Creating and maintaining systems and processes to track, validate, and store UPL data
  • Providing technical assistance to states and CMS related to UPL questions and other requests, as needed
  • Producing reports to facilitate the analysis of UPL data within and across states
  • Developing a dashboard to allow for real-time tracking and analysis of UPL information
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Project Impact

The UPL/DSH project team partners closely with CMS to develop tools and processes—supported with technical assistance—that improve the efficiency of oversight activities, ensure accountability, and increase transparency in payments to Medicaid providers.

- Eric Morris, Researcher, Mathematica

Related Staff

Eric Morris

Eric Morris

Researcher

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Ella Pestine

Ella Pestine

IT Program Manager

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Jenn Guillen

Jenn Guillen

IT Portfolio Manager

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