Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
Should the rate of required exclusions be reported with the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure's Part 1 performance rate?
The measure excludes plan members who are not ambulatory from the measure rate, but it is not necessary to report the number of members excluded with the measure’s performance rate.
FAQ ID:89006
SHARE URLIs a specific screening tool required for the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure?
No, a specific screening tool is not required for this measure. However, potential screening tools may include the Morse Fall Scale and timed Get-Up-And-Go test.
FAQ ID:89011
SHARE URLWhat is the difference between a screening (Part 1) and a risk assessment (Part 2) for the purposes of calculating the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure?
A falls screening is an evaluation of whether a Managed Long Term Services and Supports plan member has experienced a history of falls and/or problems with balance or gait. A falls risk assessment includes a balance/gait assessment and one other assessment component and should only be performed for members with a documented history of falls (at least two falls or one fall with injury in the past year).
FAQ ID:89016
SHARE URLHow does this durable medical equipment (DME) limit on federal financial participation (FFP) affect those states that are 90% managed care?
As we explained in the January 4, 2018 letter, only those items provided in the Medicaid program on a fee-for-service (FFS) basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the FFP limitation. If a state is 90% managed care the state would only have to show compliance or a demonstration with the 10% of FFS utilization and expenditures for the relevant DME items.
FAQ ID:93531
SHARE URLDo the managed care organizations (MCOs), who are contracted to provide services to our Medicaid clients, have to comply with the durable medical equipment (DME) limit on federal financial participation (FFP)?
So long as the MCOs are not paid on a fee-for-service (FFS) basis, MCOs are not covered under this statute or subject to the limit on FFP. Only the relevant DME items provided in FFS are included in this limit.
FAQ ID:93536
SHARE URLAre states that provide durable medical equipment (DME) through a managed care arrangement required to submit the reconciliation data?
Only those items provided in the Medicaid program on a fee-for-service basis are to be included in the aggregate expenditure calculation. DME reimbursed under a Medicaid managed care arrangement or a Medicaid competitive bidding contract are not subject to the federal financial participation limitation.
FAQ ID:93541
SHARE URLCenters for Medicare & Medicaid Services is saying this durable medical equipment (DME) limit on federal financial participation is applicable only to fee for service (FFS). How about the Home and Community-Based Services (HCBS) waiver programs?
If the HCBS waiver includes FFS payments for DME, the state’s expenditures for DME would be subject to the limit.
FAQ ID:93546
SHARE URLHow is the demonstration year defined? For example, if a state has a fiscal year starting on July 1, 2016 and ending on June 30, 2017, is the Upper Payment Limit (UPL) demonstration entered with the SFY 2016/17 State Plan Amendment considered to be a "2016 demonstration" or a "2017 demonstration"?
The UPL demonstration year is defined according to the last year encompassed by the demonstration. For example, a UPL covering the period 07/01/2016 to 06/30/2017 is defined as the 2017 UPL.
FAQ ID:92231
SHARE URLHow should more than two adjustments to the per diem be addressed in the nursing facility template for both Medicare and Medicaid Per Diem?
A state may report adjustments by using the following variables: Adjustments to Medicare Per Diem #1 - Variable 212.1 and Adjustments to Medicare Per Diem #2 - Variable 212.2 for the Medicare Per Diem and Adjustment to Medicaid Per Diem #1 - Variable 314.1 and Adjustment to Medicaid Per Diem #2 - Variable 314.2 for the Medicaid Per Diem. A state may report more than one adjustment under a single variable. For example, if the state has three adjustments to their Medicaid per diem, one of these adjustments can be reported in variable 314.1 and the other two adjustments can be added together and reported in variable 314.2. When reporting any adjustment, the state must provide a detailed description of the adjustment(s) in the notes tab.
FAQ ID:92296
SHARE URLHow should cost data reported for a partial year be treated either when one hospital acquires another hospital or a hospital ceases operation?
When a hospital acquires another hospital, the state should use all available data to determine the UPL and work with CMS to assure appropriate reporting. When a hospital ceases operation, the state should not annualize data if it does not cover a 12-month period.
FAQ ID:92391
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