Frequently Asked Questions

The MLTSS assessment and care planning measures include:

• LTSS Comprehensive Assessment and Update
• LTSS Comprehensive Care Plan and Update
• LTSS Shared Care Plan with Primary Care Practitioner(PCP)
• LTSS Reassessment/Care Plan Update after Inpatient Discharge
• Screening, Risk Assessment, and Plan of Care to Prevent Future Falls: Falls Part 1 (Screening) and Falls Part 2 (Risk Assessment and Plan of Care)

FAQ ID:89066

It is recommended that MLTSS plans report both rates. However, if the state believes there are valid reasons for not reporting both rates, such as costly changes in assessment and care planning forms and information technology systems, it might consider phasing in the supplemental rates over time. For instance, in the first year of measure use (for example, measurement year 2018), the state could require MLTSS plans to report just the core rate, and then require that MLTSS plans report both core and supplemental rates for measurement year 2019 or 2020. Although they are called "supplemental rates," they are still very important, and should be viewed as "aspirational." MLTSS plans should strive to cover more assessment and care plan elements over time.

FAQ ID:89071

Value sets are the complete set of procedure and diagnostic codes used to identify a service or condition included in a measure. One of the assessment and care planning measures—LTSS Reassessment/Care Plan Update after Inpatient Discharge—uses value sets to identify potentially planned hospitalizations. Please see "Do I need to use value sets to calculate these measures? If so, where can I find the value sets?" for more information regarding using value sets for the three institutional rebalancing and utilization measures.

View the value sets (XLSX, 2.88 MB). Please 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:89076

Yes, the same sample can be used for Part 1 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure as the LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, and LTSS Shared Care Plan with Primary Care Practitioner measures.

FAQ ID:89081

Yes, the assessment for the LTSS Comprehensive Assessment and Update measure is required to take place in the member’s home as a face-to-face discussion unless certain exceptions are met. These exceptions include circumstances in which:

• The member was offered an in-home assessment and refused the in-home assessment (either refused to allow the care manager into the home or requested a telephone assessment instead of an in-home assessment).
• The member is residing in an acute or post-acute care facility (hospital, skilled nursing facility, other post-acute care facility) during the assessment time period.
• The state policy, regulation, or other state guidance excludes the member from a requirement for in-home assessment.

FAQ ID:89086

There must be documentation of the refusal, which would result in exclusion from the measure. The rate of exclusion due to a member refusing to participate should also be reported along with the measure performance rate.

FAQ ID:89101

There must be documentation that at least three attempts were made to reach the member, and that the member could not be reached, which would result in exclusion from the measure. The rate of exclusion due to inability to reach a member should also be reported along with the measure performance rate.

FAQ ID:89106

Yes, the denominator for this measure includes all MLTSS members with a care plan meeting the criteria outlined in the LTSS Comprehensive Care Plan and Update measure core rate.

FAQ ID:89201

A PCP is a physician, non-physician (for example, nurse practitioner, physician assistant), or group of providers who offers primary care medical services. However, a care plan can be shared with a medical care practitioner other than the PCP if the practitioner is identified by the member as the primary point of contact for their medical care. Therefore, any medical care practitioner identified by the member as the primary point of contact for their medical care is considered their PCP for the purpose of calculating the measure.

FAQ ID:89206

The care plan is shared with the PCP to promote coordination of medical and LTSS services.

FAQ ID:89211