Frequently Asked Questions

No; discharges for planned hospital admissions are excluded from the measure denominator. Identify planned discharges using the value sets (XLSX, 2.88 MB).

FAQ ID:89236

Yes, both the re-assessment and the care plan must include each of the nine specified core elements. The re-assessment and care plan must be done face-to-face unless there is documentation that the member refused a face-to-face encounter.

FAQ ID:89241

The denominator for the Reassessment/Care Plan Update after Inpatient Discharge measure is identified through administrative claims for inpatient discharges. Managed care plans that are not the primary payer for inpatient care, which is usually covered under a medical benefit, do not routinely have reliable access to administrative claims for inpatient stays to identify individuals who are eligible to be counted in the measure denominator. Therefore, the eligible population for this measure is restricted to individuals who receive both medical and LTSS benefits through the managed care plan providing MLTSS.

FAQ ID:89246

If MLTSS plans can obtain timely, complete, and accurate inpatient claims data for their members, then a state may choose to deviate from the measure specifications to require MLTSS plans not providing medical benefits report this measure. For example, because the timely transfer of information between hospitals and MLTSS plans is key to ensuring smooth transfers between settings of care, MLTSS plans may have access to hospital discharge data through state or regional health information exchanges. In some cases, MLTSS plans are working closely with hospitals to share timely information about admissions and discharges. In addition, some states have the data and capacity to construct this measure for MLTSS plans using Medicare claims data for Medicare- Medicaid dual eligible beneficiaries (see more information about state access to Medicare claims data).

FAQ ID:89251

A reassessment with the member after they have been discharged from an inpatient facility is required to determine whether a member has had a change (or no change) in their LTSS needs. Even if the reassessment conducted post-discharge finds no change in a member’s LTSS needs, the second rate for this measure (Reassessment and Care Plan Update after Inpatient Discharge), Managed Long Term Services and Supports (MLTSS) plan care managers should conduct a care plan update and document that they considered each of the nine core elements of the care plan, and determined that the plan of care for each element remains the same; documentation of “no changes” in the care plan as a whole does not meet the numerator criteria.

FAQ ID:89256

The following measures assess institutional rebalancing and utilization:

• LTSS Admission to an Institution from the Community
• LTSS Minimizing Institutional Length of Stay
• LTSS Successful Transition after Long-Term Institutional Stay

FAQ ID:91101

Yes. Value sets are the complete set of procedure and codes used to identify a service or condition included in a measure. All three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay—use the "Institutional Facility"value set (XLSX, 2.88 MB). See Table 2 in the "LTSS Value Sets to Codes" tab. Table 1 in the "LTSS Measures to Value Sets" tab shows each value set needed for each measure.

FAQ ID:91106

No, include paid claims only (days denied for any reason should not be included) for all three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay.

FAQ ID:91111

The traditional MEQC program at 42 CFR § 431.810 through 431.822 was originally designed to implement sections 1902(a)(4) “Administration Methods for Proper and Efficient Operation of the State Plan” and 1903(u) “Limitation of FFP for Erroneous Medical Assistance Expenditures” of the Social Security Act (the Act). The program required annual state reviews of Medicaid cases identified through a statistically valid statewide sample of cases selected from the state’s eligibility files. The reviews were conducted to determine whether the sampled cases meet applicable Medicaid eligibility requirements. The program evolved over time to allow states the option of selecting specific areas of focus within the Medicaid program for their annual MEQC reviews.

On July 5, 2017, CMS published a final regulation entitled “Changes to the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) Programs (CMS-Medicaid Coordination of Benefits8- F).” This final rule updated the MEQC and PERM programs based on the changes to Medicaid and Children’s Health Insurance Program eligibility requirements under the Patient Protection and Affordable Care Act. The new regulation has restructured the MEQC program into an ongoing series of pilots that states are required to conduct during the two off-years between triennial PERM review years. The MEQC portions of the regulation are now covered by 42 CFR §§ 431.800-820.

FAQ ID:93416

The regulation requires states to submit a pilot planning document to CMS by November 1 of the year in which each state’s PERM review year ends. The pilot planning document must describe how states will conduct their active and negative case reviews and must be approved by CMS before the MEQC pilots can begin. In addition, the regulation requires states to submit case-level reports and corrective action plans to CMS by August 1 of the year after the MEQC review period ends. The specifications for the MEQC pilot planning documents are provided in the MEQC sub-regulatory guidance effective August 29, 2018. More details on the specifications of the case-level reports and corrective action plans are included in a second round of guidance, MEQC sub-regulatory guidance effective October 22, 2018.

FAQ ID:93421