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Frequently Asked Questions

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.

Showing 1 to 6 of 6 results

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

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Is 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

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What 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

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Are there any circumstances that would allow a state to apply the same Upper Payment Limit (UPL) demonstration to multiple years?

When the data that factors into the state's UPL demonstration has not changed from one year to the next, then the state could apply the same overall UPL demonstration to the following year. The state must submit a justification to support the application of a previous year's UPL demonstration to another year.

FAQ ID:92221

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Can states that pay for inpatient hospital services using Diagnosis Related Grous (DRGs), but historically used a cost-based UPL, continue to use the cost-based Upper Payment Limit (UPL) method?

Yes, states may use UPL methodologies that are different from their payment methodologies. For example, a state may pay for inpatient hospital services using a Medicaid APR-DRG methodology, but use a cost methodology to compute the Medicare upper payment limit for its UPL demonstration.

FAQ ID:92386

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May a state use all-payer data or the Medicare-specific data from the Medicare Hospital Cost Report (CMS Form 2552) to calculate the cost-to-charge ratios?

Yes, a state may choose between using all-payer data or Medicare-specific data from the Medicare Hospital Cost Report (CMS Form 2552) to determine the cost-to-charge ratios.

FAQ ID:92406

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