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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.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.

FAQ Library

Showing 1 to 10 of 27 results

Should I include discharges resulting in readmission to the institution in the Long Term Services and Supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?

No, discharges that result in readmission to the institution within 60 days of discharge from the institution do not meet the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator criteria.

FAQ ID:91146

When counting the duration of a member's stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator calculation, should I include the day of discharge?

Do not count the day of discharge unless the member’s admission and discharge occurred on the same day. If the admission and discharge occurred on the same day, the number of days in the stay is equal to one.

FAQ ID:91156

If there is no discharge, how should I calculate the length of stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?

If there is no discharge, calculate the length of stay as the date of the last day of the measurement year minus the institutional facility admission date.

FAQ ID:91166

Are the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measures risk-adjusted?

Yes, the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long- Term Institutional Stay measures are risk-adjusted based on the members’ dual eligibility status, age and gender, diagnoses from the institutional facility admission, and number of hospital stays and months of enrollment in the classification period. See the risk adjustment weights needed for these measures are in the risk adjustment tables (XLSX, 59.69 KB).

FAQ ID:91171

Should a member's admission be included in the Long Term Services and Supports (LTSS) Successful Transition after Long-Term Institutional Stay measure denominator if it was a direct transfer from another institution?

No, do not include these admissions in the LTSS Successful Transition after Long-Term Institutional Stay measure denominator.

FAQ ID:91176

Would an admission to an institutional facility following a discharge from another facility two days prior be considered a direct transfer?

No, these would be two distinct institutional stays; do not remove this admission from the Long Term Services and Supports Successful Transition after Long-Term Institutional Stay measure denominator.

FAQ ID:91186

How should I account for a member's death when calculating the Long Term Services and Supports Successful Transition after Long-Term Institutional Stay member's numerator and denominator?

If the member died in the institution or within one day of discharge from the institution, do not include their admission in the denominator. Members who died one day after discharge are excluded because of the high number of deaths the day after discharge observed while testing this measure; such members are unlikely to have been discharged alive. If the member died between day 2 and day 60 during the 60 days following discharge from the long-term institutional stay, do not include their discharge in the numerator.

FAQ ID:91191

When a state pays a provider at reconciled cost using Certified Public Expenditures during the period covered by the Upper Payment Limit (UPL) demonstration, how should the provider's data be treated?

The UPL limits payment to the Medicare rate or cost. Providers paid at reconciled cost may receive no more than their reconciled amount. As a result, states cannot attribute the “UPL room” from other providers to pay additional amounts to any provider paid at reconciled cost. Due to this payment limitation, states should not include any provider paid at reconciled cost in their UPL demonstrations; however, they must account for these providers. Specifically, states must include with their UPL submissions documentation of those providers paid at reconciled cost and confirm by provider use of either a Medicare cost report or Centers for Medicare & Medicaid Services-approved cost report template to identify allowed cost. Further, states must document the ownership status (state owned, non-state government owned, or private) of each provider.

FAQ ID:92436

Our state included dental services along with physician (non-dental) services in our state's Upper Payment Limit (UPL) demonstration of the practitioner Average Commercial Rate (ACR) using the Medicare Equivalent of the ACR. Should we keep both services together in one demonstration or should we separate the services out for two different ACR demonstrations?

Dental services are not covered under Medicare, which means the state may not compare Medicaid rates for comparable dental services for the Medicare Equivalent of the ACR. The state may calculate a dental ACR in order to make supplemental payments to dental services providers and continue to calculate the Medicare Equivalent of the ACR for other services covered by Medicare. The state should submit two separate ACR demonstrations, one for dental services and one for physician (non-dental) services. This will involve completing two versions of the Office of Management and Budget-approved template. If the same provider provides both physician and dental services the state would differentiate the provider information between the two demonstrations by appending the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the physician ACR as 123456-A and in the dental ACR as 12345-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number.

FAQ ID:92441

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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