Georgia Medicaid Supplemental Payments and UPL Guide (2026)

Upper Payment Limit payments are one of the largest and least understood Medicaid financing mechanisms in America. Together with Disproportionate Share Hospital payments, graduate medical education payments, and managed care directed payments, UPL is part of the supplemental payment architecture that channels billions of federal Medicaid dollars to state hospitals, nursing homes, physician practices, and other Medicaid providers each year.

Families never see UPL on a claim because UPL payments do not pass through to individual services. But UPL is what keeps the hospital where a family member gets a stroke treated open, what keeps the nursing home where a parent lives staffed, and what keeps the physician practice the family relies on participating in Medicaid.

This guide translates Georgia's UPL framework for families. We walk through the federal statutory architecture under Title XIX of the Social Security Act and the related federal Medicaid regulations, explain how provider classes are defined, how the state non-federal share is generated, and how the Georgia Department of Community Health (DCH) implements UPL through the Hospital Provider Payment Program (HPPP), the Indigent Care Trust Fund, and intergovernmental transfers from public hospital authorities. The goal is not to teach families how to lobby for higher provider payments but to demystify a system that keeps the providers families depend on financially viable.

If you have questions about Georgia Medicaid eligibility, services, or provider participation, call DCH Member Services at 1-866-211-0950. For long-term care advocacy, call the Georgia Long-Term Care Ombudsman at 1-866-552-4264.

By Brevy Care Team · Last verified May 12, 2026

UPL is a regulatory regime built on a relatively short statutory provision. Understanding the architecture starts with the statute, then moves to the federal regulations that implement it, and finally to the CMS guidance documents that shape day-to-day practice.

The Medicaid efficiency-economy-access standard

The cornerstone provision of federal Medicaid law says that state Medicaid plans must provide methods and procedures for payment that:

1. Safeguard against unnecessary utilization of care and services
2. Ensure that payments are consistent with efficiency, economy, and quality of care
3. Are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area

This dual mandate drives both the upper bound and the lower bound of Medicaid rate-setting. CMS interprets the "efficiency and economy" prong as authorizing UPL caps; states interpret the "access" prong as authorizing supplemental payments to the extent needed to maintain provider participation.

The same statutory provision that limits supplemental payments to the Medicare equivalent (the UPL ceiling) is the provision that authorizes supplemental payments in the first place (to ensure access).

Public process requirement

State plans must provide for a public process for determining payment rates for inpatient hospital services, nursing facility services, services in intermediate care facilities for individuals with intellectual disabilities, and inpatient mental hospital services. The implementing federal regulation requires public notice and opportunity for comment on significant payment changes.

Federal provider-tax limits

Federal Medicaid law regulates the use of health-care-related taxes (provider taxes, also called provider assessments) to fund the state share of Medicaid. Provider taxes must be:

• Broad-based: apply to all or substantially all providers in a class
• Uniform: apply at the same rate within the class
• Not held harmless: the state cannot guarantee that providers will receive back, through Medicaid payment, what they paid in assessment plus more

A federal "safe harbor" allows provider taxes up to a defined share of net patient revenues without intensive CMS scrutiny. Above the safe-harbor threshold, CMS applies a hold-harmless test. Consult the current CMS provider-tax guidance for the operative percentage and test.

Federal financial participation

Federal Medicaid law authorizes federal matching funds. The Federal Medical Assistance Percentage (FMAP) determines the federal share. Georgia's FMAP is set annually by HHS; consult the current CMS FMAP table for the operative figure.

UPL supplemental payments draw federal matching just like any other Medicaid expenditure. The key constraint is that the state share must come from legitimate non-federal sources, not from recycled federal dollars.

Relationship to DSH

DSH and UPL are distinct programs with separate statutory authorities. DSH is paid only to hospitals that qualify as disproportionate share. UPL is paid to all providers in the class. DSH is capped at the hospital-specific uncompensated care limit. UPL is capped at the Medicare-equivalent for the class.

A hospital may receive both DSH and UPL. The combined total cannot exceed federal limits applicable to each program separately.

The federal regulations for Georgia Medicaid UPL

The detailed mechanics of UPL live in federal regulations.

Inpatient hospital UPL

The keystone federal regulation provides that aggregate Medicaid payments to a class of inpatient hospital providers may not exceed the amount that Medicare would have paid under its prospective payment system for the same services to the same providers.

The provider classes are:

Private hospitals. Privately owned and operated. This is the largest class in most states, including Georgia.

State government-owned hospitals. Hospitals owned by the state government. In Georgia, examples include Augusta University Medical Center (a state university hospital, owned by the Board of Regents of the University System of Georgia).

Non-state government-owned hospitals. Hospitals owned by local government (county, city, hospital authority). In Georgia, examples include Grady Memorial Hospital (owned by the Hospital Authority of Fulton and DeKalb Counties), Phoebe Putney Memorial Hospital (owned by Hospital Authority of Albany-Dougherty County), and several other public hospitals.

Each class has its own separate UPL calculation. Aggregate Medicaid payments to each class (base rate payments plus supplemental payments) must not exceed the class UPL ceiling.

Outpatient hospital UPL

Federal regulations apply a parallel rule for outpatient hospital services. Same three classes (private, state government-owned, non-state government-owned). Same Medicare-equivalent calculation, but for outpatient services rather than inpatient.

Federal payment-rate regulations for inpatient hospital services

Detailed federal inpatient hospital payment rules include the prospective payment system framework. Most states (including Georgia) use a DRG-based payment methodology for inpatient hospital services that mirrors Medicare's payment structure.

Public-notice regulation

Federal regulation requires public notice of significant changes to inpatient hospital, nursing facility, ICF/IID, and inpatient mental hospital payment rates. Notice must:

• Be published in newspapers of widest circulation in each city above a defined population threshold
• Be available for public review
• Explain proposed changes and rationale
• Provide a period for public comment

Sources of the state Medicaid share

Federal regulations specify that the non-federal share of Medicaid expenditures can come from:

• State general fund appropriations
• Health-care-related taxes (subject to Section 1903(w) limits)
• Intergovernmental transfers (IGTs) from local government units
• Certified Public Expenditures (CPEs) by public providers

Federal funds cannot be used as the state share. This prohibition on "recycling" federal dollars is central to the integrity of the Medicaid financing system.

Health-care-related tax regulations

Federal regulations spell out provider-tax structure, including the broad-based and uniform requirements and the hold-harmless test.

State-share source regulation

Federal regulation specifies what counts as the state share and what does not. IGTs, CPEs, provider assessments, and general fund are eligible sources; federal funds and certain hold-harmless arrangements are excluded.

Directed payments in managed care

Added by the CMS 2016 Medicaid managed care final rule. The directed-payment framework authorizes states to direct Medicaid managed care plans to make specified payments to particular providers, subject to CMS approval. It functions as the managed care analog to UPL supplemental payments in fee-for-service.

Three types of directed payments are authorized:

Value-based purchasing arrangements. Payments tied to quality metrics, outcome measures, or value-based purchasing structures.

Provider payments based on quality metrics. Quality-based payments to specified providers.

Uniform payment increases to a class of providers. State-directed minimum payment levels that apply uniformly across a class.

CMS approval requires that the directed payment serves the goals and objectives of the state's managed care quality strategy. Subsequent CMS amendments and guidance have refined the framework.

How the UPL gap is calculated

A simplified illustration helps. Consider a private inpatient hospital class in Georgia.

Step 1: Calculate Medicare-equivalent payment. For each Medicaid inpatient discharge in the class, calculate what Medicare would have paid under its DRG payment rates and applicable adjustments. This involves applying Medicare's rates, wage adjustments, indirect medical education adjustments, disproportionate share adjustments (for Medicare DSH), and outlier payments to the Medicaid discharge data.

Step 2: Aggregate Medicare-equivalent. Sum across the class to get the total Medicare-equivalent payment for all Medicaid discharges in the class.

Step 3: Calculate actual Medicaid base payments. Sum what Medicaid actually paid (base rate DRG payments).

Step 4: UPL gap. The difference between aggregate Medicare-equivalent and actual Medicaid base payments. This is the maximum supplemental payment that can be made to the class without exceeding UPL.

Real calculations involve detailed adjustments. CMS provides UPL templates that states use to demonstrate compliance. The templates require:

• Per-discharge Medicare equivalent
• Per-discharge actual Medicaid payment
• Aggregate totals
• Class-by-class breakdown
• Documentation of methodology

Georgia DCH submits UPL templates to CMS as part of state plan amendments and as an annual demonstration.

Sources of the state non-federal share

UPL supplemental payments require state non-federal share. The four main sources are:

State general fund

The cleanest source. Some UPL programs draw on state general fund appropriations. For Georgia, general fund support has been a portion of the state share for some UPL components, but provider assessments and IGTs do much of the work.

Provider assessments (provider taxes)

Many UPL programs are financed primarily through provider assessments. Hospital Provider Assessments are the most common. The mechanics:

1. State imposes an assessment on hospitals (typically a percentage of net patient revenue).
2. State uses assessment revenue as the non-federal share.
3. State makes UPL supplemental payments to hospitals, drawing federal matching funds.
4. Net effect: hospitals as a class receive more in supplemental payments than they paid in assessments because of the federal match.

This is the mechanism that powers Georgia's Hospital Provider Payment Program (HPPP). Hospitals collectively pay the assessment and collectively receive supplemental payments that, in aggregate, exceed what they paid. Individual hospitals may pay more or less than they receive (because the redistribution prioritizes higher-Medicaid hospitals), but the class benefits as a whole.

Federal Medicaid law constrains assessment structure. The assessment must be broad-based (all hospitals in the class), uniform (same rate), and not held harmless (no guarantee that any hospital will be made whole). A federal safe harbor caps the assessment at a defined share of net patient revenue without intensive CMS review; consult the current CMS provider-tax guidance for the operative threshold.

Intergovernmental transfers (IGTs)

Funds transferred from a local government unit (county, hospital authority, city) to the state Medicaid agency. The transferring entity must have legitimate non-federal funds. The funds are used as the state share for UPL supplemental payments back to public hospitals or hospitals affiliated with the transferring entity.

Constraints under federal law:

• IGT funds must be legitimate non-federal funds (no recycling)
• Cannot violate the hold-harmless rules
• Cannot be funded back to the transferring entity in a way that nullifies the contribution

In Georgia, the Hospital Authority of Fulton and DeKalb Counties (which owns Grady) can make IGTs to DCH as part of Grady's UPL financing arrangement. The Hospital Authority of Albany-Dougherty County (which owns Phoebe Putney) and other public hospital authorities can do the same for their hospitals.

Certified Public Expenditures (CPEs)

Expenditures by a public provider (typically a public hospital or state government hospital) that are certified as Medicaid-eligible. The CPE serves as both the state share and as the basis for federal matching.

CPE example: A public hospital incurs $10 million in cost for uninsured care eligible for Medicaid. The hospital certifies the expenditure. The state claims the $10 million as Medicaid expenditure and draws federal matching funds.

CMS has tightened CPE rules over time to prevent abuse. Documentation requirements have grown substantially. A CMS final rule promulgated in the late 2000s imposed enhanced UPL data submission requirements that affected CPE practices.

HHS-OIG and GAO oversight of supplemental payments

HHS-OIG and the Government Accountability Office have audited state UPL programs extensively. Major audit themes:

Overcounting the UPL gap

Some audits have found that states overcounted the UPL gap by miscalculating the Medicare-equivalent, inflating the volume of Medicaid services, or other methodological errors.

Improper IGT mechanisms

Audits have found IGT arrangements that effectively recycled federal funds. CMS has used SMD letters and tightened state plan amendment reviews to prevent these arrangements.

Inadequate documentation

Audits have found provider class definitions, UPL calculations, and source-of-funds documentation that did not meet federal standards.

Hold-harmless violations

Audits have found provider assessment arrangements that effectively held providers harmless, violating Section 1903(w).

CMS responses have included:

• Tighter approval of state plan amendments
• Enhanced UPL data submission requirements through a CMS final rule
• Restrictions on certain IGT practices through SMD letters
• Restrictions on certain CPE practices
• Periodic SMD letters clarifying expectations

CMS State Medicaid Director Letters on supplemental payments

Mid-decade SMD on IGT practices

A CMS SMD letter from the mid-2010s addressed certain IGT practices and clarified federal expectations for the source of the non-federal share.

Late-2010s SMD on directed payments

A later CMS SMD provided detailed guidance on the directed-payment framework, including expected preprint format, evaluation criteria, and quality strategy linkage.

Early-2020s SMD updates

Subsequent CMS SMDs addressed evolving issues with directed payment programs, including value-based purchasing, minimum fee schedules, and uniform increases.

Various subsequent SMDs

Have addressed UPL data submission, provider tax structure, and many specific state programs.

The CMS managed care final rule and the shift to directed payments

The 2016 CMS Medicaid managed care final rule reshaped the supplemental payment landscape in states with substantial managed care, including Georgia. Key changes:

Directed payments became the principal vehicle. In states with substantial managed care enrollment, traditional fee-for-service UPL applies only to fee-for-service claims. The much larger managed care book of business requires directed payment structures.

Pass-through payments were phased out. Pre-2016, states could make supplemental payments to providers through managed care pass-through arrangements. The final rule phased these out over a transition period.

Quality-based directed payments became required for value-based purchasing. Directed payments must align with the state's managed care quality strategy.

Enhanced documentation requirements. States must submit detailed preprints (template documents) for CMS approval.

Georgia's transition from fee-for-service to managed care for many beneficiaries (under the Georgia Families program) required restructuring some supplemental payment practices into directed payments.

How Georgia Medicaid UPL operates

DCH Hospital Provider Payment Program (HPPP)

The HPPP is Georgia's primary UPL vehicle. Established under Georgia law and the Medicaid State Plan, the HPPP coordinates:

• Hospital Provider Assessment (provider tax under federal Medicaid provider-tax limits)
• UPL supplemental payments to private hospitals
• Coordination with DSH payments
• Coordination with the Indigent Care Trust Fund

Hospital assessments under HPPP fund the non-federal share. The state draws federal matching funds and makes supplemental payments to hospitals. The aggregate flow:

1. Hospitals pay the assessment.
2. State uses assessment revenue as state share.
3. State draws federal matching funds.
4. State makes supplemental payments to hospitals.
5. Hospitals collectively receive more than they paid because of the federal match.

DCH Inpatient Hospital UPL

Calculated and submitted to CMS using the CMS UPL template. Three classes:

Private inpatient hospitals. Most Georgia hospitals fall in this class. Examples include for-profit chains, nonprofit systems (Piedmont, Wellstar, Northeast Georgia, and others), and stand-alone hospitals.

State government-owned inpatient hospitals. Examples include Augusta University Medical Center, owned by the Board of Regents of the University System of Georgia.

Non-state government-owned inpatient hospitals. Examples include Grady Memorial Hospital (Hospital Authority of Fulton and DeKalb Counties), Phoebe Putney Memorial Hospital (Hospital Authority of Albany-Dougherty County), Memorial Health (Savannah), the Medical Center Navicent Health (Macon), Northeast Georgia Medical Center, and various other public hospital authority facilities. Class assignments can shift with ownership changes; consult the current Georgia DCH UPL template submission for the operative class.

Each class has its own UPL calculation.

DCH Outpatient Hospital UPL

Parallel calculation for outpatient services. Same three classes. Outpatient UPL has grown in importance as outpatient services have become a larger share of hospital revenue. The federal regulation that mirrors the inpatient UPL rule applies to outpatient hospital UPL.

DCH Nursing Facility UPL

Georgia operates a Nursing Facility UPL for the nursing home class. Provider assessment on nursing facilities funds the state share. Nursing facility UPL is a significant program supporting Georgia nursing home operations.

DCH Physician UPL

Georgia has had Physician UPL components for academic physician practices (faculty practice plans at Augusta University and Emory through Grady) and for federally qualified health center physicians. Physician UPL is structurally similar but uses Medicare physician fee schedule rates as the equivalent benchmark.

Directed payments in managed care

Georgia's CMOs operate under approved state plan amendments and directed payment preprints. Directed payments fund specified provider categories, typically including:

• Hospital uniform increases
• Pediatric specialty
• Federally qualified health centers
• Academic medical center physicians
• Behavioral health

Intergovernmental Transfers in Georgia

Public hospital authorities (Grady, Phoebe Putney's authority, Hall County's authority for NGMC, and others) can make IGTs to DCH as the state share for UPL supplemental payments back to those same hospitals. The structure is carefully designed to comply with federal hold-harmless and recycling restrictions.

State General Fund

DCH receives general fund appropriations as part of the Medicaid state share, including for some UPL components.

Coordination among DSH, UPL, ICTF, and HPPP

The four major Georgia hospital financing programs are distinct but interrelated:

DSH (Disproportionate Share Hospital). Federal Medicaid payments to hospitals serving a disproportionate share of low-income patients. Hospital-specific limit equals uncompensated care costs.

UPL (Upper Payment Limit). Supplemental payments up to the Medicare-equivalent for the provider class.

ICTF (Indigent Care Trust Fund). State trust fund used to pool resources for safety-net hospital support, including funding DSH and other indigent care expenditures.

HPPP (Hospital Provider Payment Program). Hospital assessment + supplemental payment mechanism that interacts with UPL and DSH.

For a hospital, total Medicaid revenue may include base rate payments + DSH + UPL + directed payments. The hospital's total cannot exceed federal limits applicable to each category. For example, even if a hospital is below its UPL ceiling, it cannot receive DSH payments that exceed its uncompensated care costs.

Family-facing implications

Why UPL matters for families

UPL is invisible on a claim. A family member with Medicaid never sees a UPL payment line item. But UPL is what keeps the hospital, nursing home, or physician practice operating at a financial level that permits Medicaid participation.

Without UPL, many providers would withdraw from Medicaid or close entirely. The 2020-2025 wave of rural hospital closures in Georgia and other states has been driven in part by inadequate supplemental payment support. Rural hospitals depend disproportionately on Medicaid (because their patient populations have higher Medicaid penetration) and therefore on the UPL and DSH financing that supports Medicaid participation.

When UPL is in the news

Families occasionally hear about UPL when:

• State budgets debate the Hospital Provider Assessment level
• A hospital makes a financial filing mentioning UPL revenue
• A CMS state plan amendment changes a UPL methodology
• A federal court considers a UPL methodology challenge
• An OIG audit finds methodological problems with a state UPL program

What families can do

Family advocacy organizations and the Georgia Hospital Association have been active in state and federal UPL policy. Families interested in Medicaid financing policy can engage through:

• Public comment on state plan amendments
• Public comment on federal CMS rulemakings
• Legislative advocacy with state legislators
• Hospital association engagement
• Patient advocacy coalitions

But UPL itself is not a family-actionable program. The level of UPL payment to a particular hospital is determined by state methodology and CMS approval, not by individual member action.

Worked examples

These examples illustrate how UPL operates in practice.

Eleanor, 78, Atlanta: UPL underwriting public hospital care

Eleanor is dual eligible (Medicare + Medicaid). She has a hemorrhagic stroke and is rushed to Grady Memorial Hospital's emergency department. Grady stabilizes her, admits her to the neurology ICU, and provides 14 days of acute care. After discharge, Eleanor enters acute rehabilitation at the same facility, then returns home with home health.

How UPL works in Eleanor's case: Eleanor's bill is paid first by Medicare (as primary payer) for Medicare-covered services. Medicaid pays the secondary balance and the Medicare cost-sharing. Grady's total Medicaid revenue for Eleanor includes the base Medicaid payments plus Grady's share of UPL supplemental payments to the non-state government-owned hospital class.

Grady is one of the largest recipients of UPL and DSH funding in Georgia. The Hospital Authority of Fulton and DeKalb Counties makes intergovernmental transfers to DCH as the state share for UPL supplemental payments back to Grady. Without UPL, DSH, and ICTF support, Grady's Medicaid losses would be massive and its operations unsustainable.

Eleanor herself is not aware of UPL. She sees only the care, not the financing. But the care she receives is possible because Grady is financially viable, which is possible because of UPL and related supplemental payments.

Marcus, 45, rural Bulloch County: UPL underwriting critical access hospital

Marcus has a serious car accident and is taken by EMS to East Georgia Regional Medical Center in Statesboro. East Georgia Regional is a small hospital serving a five-county rural area. Marcus is stabilized, transferred to a tertiary care center in Savannah for definitive care, and eventually transferred back to East Georgia Regional for rehabilitation closer to home.

How UPL works: East Georgia Regional is a private (non-government) hospital. It receives UPL supplemental payments through its membership in the private hospital UPL class. Rural hospitals like East Georgia Regional depend heavily on UPL because their per-discharge Medicaid base payments are below the Medicare equivalent (the UPL ceiling), creating a substantial UPL gap that can be filled with supplemental payments.

The Hospital Provider Assessment that East Georgia Regional pays into the HPPP is more than offset by the UPL supplemental payments it receives back, because of the federal match.

If UPL supplemental payments were reduced (for example, through a federal provider-tax limitation or a federal court ruling on the methodology), East Georgia Regional's financial position would deteriorate. Closure of rural hospitals like East Georgia Regional would force patients like Marcus to travel hours for trauma stabilization, with potentially fatal consequences.

Aisha, 32, Savannah: private hospital UPL and Hospital Provider Assessment

Aisha has a high-risk pregnancy with preterm labor at 31 weeks. She is admitted to Memorial Health University Medical Center in Savannah. Memorial Health stabilizes her, manages her labor, and ultimately delivers her son at 33 weeks. Her son spends six weeks in the neonatal ICU.

How UPL works: Memorial Health is in the private hospital UPL class (under recent ownership changes; the exact class can shift with ownership). Memorial Health pays into the Hospital Provider Assessment and receives UPL supplemental payments through the HPPP.

For Aisha's high-cost obstetric and neonatal admissions, Medicaid base payments are well below the Medicare equivalent (the UPL ceiling). UPL supplemental payments help close this gap, enabling Memorial Health to continue accepting Medicaid for obstetric and neonatal care.

Without UPL, many private hospitals would reduce or eliminate obstetric services, which are already loss-leaders for many hospital systems. The obstetric care unit closures sweeping rural America have been concentrated in areas with inadequate supplemental payment support.

Jamil, 8, CHOA: pediatric specialty UPL

Jamil has a complex congenital heart condition. He has had three open-heart surgeries at Children's Healthcare of Atlanta (CHOA) and continues to be followed by CHOA pediatric cardiology. His Medicaid covers the care.

How UPL works: CHOA is in the private hospital UPL class (Children's Healthcare of Atlanta is a nonprofit health system, structured as a private entity rather than a government-owned hospital). CHOA receives UPL supplemental payments through HPPP and through directed payments in managed care.

Pediatric specialty hospitals like CHOA, Atlanta Children's, and certain academic medical centers depend particularly heavily on UPL because pediatric specialty care has high fixed costs and high Medicaid mix (Medicaid covers a large share of pediatric care, particularly specialty care). UPL supplemental payments help sustain pediatric specialty care at the level needed for children like Jamil.

Diana, 84, Macon: outpatient UPL and obstetric services

Diana has Medicare Parts A and B plus Medicaid wrap (she is dual eligible). She receives ongoing outpatient cardiology, diabetic management, and chronic kidney disease care at the Medical Center, Navicent Health in Macon. She makes 25 to 30 outpatient visits per year.

How UPL works: Navicent is in the non-state government-owned hospital UPL class (owned by the Hospital Authority of Macon-Bibb County or its successor structure). Diana's outpatient visits draw base Medicaid payments plus outpatient UPL supplemental payments under the federal outpatient hospital UPL regulation.

Outpatient UPL has grown in importance as more services have shifted from inpatient to outpatient settings. For Navicent, outpatient UPL is now a significant share of total UPL revenue.

Tasha's father, 70, Albany: provider assessment + UPL + IGT for Phoebe Putney

Tasha's father is dual eligible and receives chronic care at Phoebe Putney Memorial Hospital in Albany. Phoebe Putney is owned by the Hospital Authority of Albany-Dougherty County (a public hospital authority).

How UPL works: Phoebe Putney is in the non-state government-owned hospital UPL class. The Hospital Authority makes intergovernmental transfers to DCH as part of the state share for UPL supplemental payments. Phoebe Putney also pays into the Hospital Provider Assessment and receives back UPL supplemental payments.

Phoebe Putney is one of the safety-net anchors of southwest Georgia. The combination of UPL, DSH, ICTF, and the Hospital Provider Assessment enables Phoebe Putney to continue providing care for Tasha's father and the broader Medicaid population of southwest Georgia, including in rural counties where Phoebe is the only tertiary care option.

Frequently asked questions

Key contacts

This article is for general information only and is not legal, tax, or medical advice. Medicaid supplemental payment methodologies change frequently. Verify current contact numbers and program details directly with DCH or qualified counsel before acting on any specific matter.

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