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.
Certification Forms
HHSC conducts an annual open enrollment period from December 1st to December 31st. To participate in the ICF/IID UPL Supplemental Payment program, eligible facilities must submit a certification form by accessing the LTSS portal during the enrollment period. Enrollment is voluntary and previous certifications do not carry forward to the new federal fiscal period.
The ICF UPL Certification form can be accessed by visiting the LTS Portal: (http://rad-apps.hhsc.texas.gov/icfupl/Login.aspx).
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. It is imperative that the facility completes accurate billing for services at the end of each quarter to ensure UPL calculations are accurate and timely. 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 the facility transferred the maximum IGT amount in each of the first three quarters.
ICF UPL FFY 25
- Quarterly Payments