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

Annually, CMS will request a list of covered durable medical equipment HCPCS codes from the Medicare Pricing, Data Analysis and Coding Contractor. Once the list is received, CMS will distribute the list through the CMS Regional Office Associate Regional Administrator.

FAQ ID:93671

To address claims run-out and ensure compliance with the FFP limit, we recommend states with these concerns conduct interim FFP limit demonstrations for DME no later than three months after the end of the calendar year for the previous calendar year (that is, January 1-December 31). The interim DME FFP limit demonstration will be due by March 31 of each calendar year and will contain data for the period of January 1 to December 31 of the preceding year. The final demonstration would be due one year later on March 31 and include all claims received during the run-out period dates of service within the interim demonstration period. The interim demonstration process should provide states with an understanding of potential violations of the FFP to make any necessary budgeting and rate changes. This method is being used to allow provide for a reasonable claims run out period as allowed under 42 CFR 424.44, which states that claims must be filed no later than one calendar year after the date of service.

FAQ ID:93676