Frequently Asked Questions

No. Although a comprehensive assessment may include falls risk assessment elements, this measure does not require the risk assessment elements to be documented as part of a comprehensive assessment. For this measure, a falls risk assessment is considered complete if the member record includes any documentation of a balance/gait assessment, and documentation of assessment of postural blood pressure, vision, home fall hazards, and/or medications.

FAQ ID:88961

No, the components can be completed during separate encounters, provided they are documented in the member record as having been performed between August 1 of the year prior to the measurement year and December 31 of the measurement year.

FAQ ID:88966

No, a standardized tool is not required, although documentation of use of a standardized tool (for example, Get Up & Go, Berg, Tinetti) would meet the balance/gait assessment component of the measure.

FAQ ID:88971

Yes, the same tool may be used to conduct the screening and risk assessment for the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure.

FAQ ID:88986

No. Although a comprehensive care plan may include the elements comprising a plan of care to prevent future falls, the measure does not require the plan of care elements to be documented as part of a comprehensive care plan. For this measure, a plan of care is considered complete if the member record includes any documentation of exercise therapy or referral to exercise between August 1 of the year prior to the measurement year and December 31 of the measurement year.

FAQ ID:88991

Yes, the rate of exclusion for members who refused an assessment and/or a plan of care needs to be reported with the measure’s performance rate.

FAQ ID:88996

No, the sample for Part 2 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure is different from the systematic sample used for the LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, LTSS Shared Care Plan with Primary Care Practitioner, and Part 1 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measures. Members included in the sample for Part 2 of this measure must have a documented history of falls (at least two falls or one fall with injury in the past year), including documentation of plan member self-reported history of falls.

FAQ ID:89001

No, an upper payment limit demonstration considers all Medicaid payments (base and supplemental). States must conduct UPL demonstrations for the applicable services described in State Medicaid Director Letter (SMDL) 13-003 regardless of whether a state makes supplemental payments under the Medicaid state plan for the services.

FAQ ID:92191

Where inflation is not applied to property costs, please separate out this cost from the Medicare UPL by reporting these amounts in variable 402 - Adjustment to the Medicare UPL.

FAQ ID:92361

Section 1902(a) (25) (I) of the Act defines ""health insurers"" to include self-insured plans, group health plans (as defined in section Medicaid Management Information Systems (MMIS)(l) of the Employee Retirement Income Security Act of 1974 (ERISA)), service benefit plans, managed care organizations (MCOs), pharmacy benefit managers (PBMs), and ""other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service."" Workers' compensation, automobile insurance, and liability insurance plans all are included within the definition of ""health insurer"" for purposes of this section and the requisite state laws which must be enacted pursuant to it.

The CMS interprets ""other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim"" to include:

1. Prepaid Inpatient Health Plans (PIHPs) and Prepaid Ambulatory Health Plans (PAHPs). For purposes of Medicaid managed care, PIHPs and PAHPs are entities that contract with the state to deliver Medicaid-covered services; in that context, they would also be considered ""other parties that are, by contract, legally responsible for payment of a claim for a health care item or service;"" and,
2. Such entities as third party administrators (TPAs), fiscal intermediaries, and managed care contractors, which administer benefits on behalf of the riskbearing plan sponsor (e.g., an employer with a self-insured health plan). CMS recognizes that entities such as PBMs and TPAs do not necessarily have ultimate financial liability, but, to the extent that they are required, by contract or otherwise, to review claims and authorize payment by the plan sponsor, they are included within the definition of ""third party"" and ""health insurer"" for purposes of section 1902(a) (25) of the Act.

Nothing in revisions to the Social Security Act made by the Deficit Reduction Act of 2005 (DRA) imposes new liability to pay claims on entities that do not otherwise bear such liability. Nor does section 1902(a) (25) of the Act negate any right of indemnification against a plan sponsor or other entity with ultimate liability for health care claims by a contracting party that pays the claims.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94021