Frequently Asked Questions

The Medicare Savings Program (MSP) Model application can be found here: Medicare Savings Programs (MSP) Model Application for Medicare Premium Assistance

FAQ ID:95161

No. However, when identifying the measure’s denominator from the eligible population, there are a few cases in which you should not include member months. For example, do not include months when the plan member was residing in an institutional facility for the entire month (that is, there were no days in the month spent residing in the community). If a member died, do not include the month during which the member died and any subsequent months of enrollment in the measure’s denominator.

FAQ ID:91116

When calculating the measure’s numerator (number of admissions to an institution), do not include admissions that are direct transfers from another institution, admissions from the hospital that originated from an institution, or admissions for individuals who do not meet the continuous enrollment criteria. If the member’s admission resulted in death in the institution or death within one day of discharge from the institution, do not include the admission in the numerator.

FAQ ID:91121

Yes, people admitted to an institution who were residing in the community prior to their admission may include those residing in assisted living, adult foster care, or another setting that is not defined as an institution.

FAQ ID:91131

Yes, this measure is risk-adjusted, using risk stratification by age. Results are reported separately for four age groups (18-64, 65-74, 75-84, 85 and older) for each of the length of stay classifications (short-term stay, medium-term stay, and long-term stay).

FAQ ID:91136

CMS released an Informational Bulletin (CIB) discussing the change in federal financial participation (FFP) for EQR that was effective May 6, 2016. The CIB includes revised claiming instructions for the CMS-64 and a sample form. It is available at Medicaid.gov on the EQR webpage, under Technical Assistance Documents, and available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib061016.pdf (PDF, 279.08 KB).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93471

Yes. We remind states that the requirement that the final capitation rate be specified in the contract is not a new requirement, see section 438.6(c)(2)(ii) of the 2002 final rule. The amount of payment for performance-in this context, the final capitation rate-is a primary component of any contract and must be included for purposes of verifying claims for Federal Financial Participation (FFP) on the CMS-64. In the Final Rule at page 27595, in the context of risk adjustment, CMS suggested that the payment terms under the contract could be identified in an appendix, or additional supporting documentation, to the contract for ease of updating the information when risk adjustment is applied. The state must submit a formal contract amendment when the final capitation rates differ from the payment terms in an approved contract.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:93171

Under section 438.370, the enhanced match of 75 percent is available for the EQR-related activities described in section 438.358 if all of the following conditions are met:

• The EQR activity is performed on a managed care organization (MCO) by an entity meeting the requirements of a qualified EQRO in section 438.354 or its subcontractor;
• The activity is performed pursuant to a contract approved by CMS; and
• The activity is performed in accordance with a protocol issued by CMS.

FFP at the 50 percent matching rate is available for mandatory and optional EQR-related activities for PIHPs, PAHPs, and affected PCCM entities, regardless of whether the activities were conducted by an EQRO or another entity. FFP at the 50 percent matching rate is also available for EQR and related activities performed for MCOs that are conducted by an entity that is not a qualified EQRO. This is a change from previous regulations, under which the enhanced match was available for EQR of PIHPs to the same extent as MCOs. This provision took effect May 6, 2016.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94646

Regardless of whether an EQRO contract is approved before or after May 6, 2016, the change in FFP for EQR-related activities was effective May 6, 2016 for expenditures incurred by the state on or after May 6, 2016. Per general CMS-64 claiming principles, a state incurs an expenditure that may be claimed on the CMS-64 on the date the state pays the EQRO for the completed performance of the contracted EQR-associated activity.

The change to the FFP match rate for expenditure reporting takes effect in the middle of a quarter, which means that states must ensure that claims for expenditures for EQR activities affected by the change in FFP which were paid before May 6th and claims for expenditures which were paid on or after May 6th are reported separately. For only the quarter ending June 30, 2016, the CMS-64 EQRO Line 17 will allow states to report state expenditures associated with PIHP EQRO activities paid prior to May 6, 2016 and claim the enhanced 75 percent match. State expenditures associated with PIHP EQRO activities paid on or after May 6th must be claimed at the 50 percent matching rate.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94651

CMS expects to first issue revised protocols for the current mandatory and optional EQR-related activities in the Fall of 2017. We expect to issue the protocol for the new mandatory EQR activity relating to the validation of network adequacy later in 2017 or early 2018. States will have up to one year from the publication of the protocol to implement the new mandatory EQR activity.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 185.26 KB)

FAQ ID:94656