Frequently Asked Questions

Managed Long Term Services and Supports (MLTSS) plan managers should provide training on proper documentation practices to care managers and other delegated staff. States and MLTSS plans could consider including data field entry options to remind care managers to record all results of the assessment, even if findings are negative, that is, the member does not have a problem or need assistance or services. For example, states and plans could include a question in the member’s record that requires the care manager to document both whether an assessment was performed and whether a problem was identified, along with another required field to include the details of the problem if there was a problem identified.

FAQ ID:89046

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

No, an upper payment limit demonstration considers all Medicaid payments (base and supplemental). States must conduct UPL demonstrations for the applicable services described in State Medicaid Director Letter (SMDL) 13-003 regardless of whether a state makes supplemental payments under the Medicaid state plan for the services.

FAQ ID:92191

The cost of the tax should be reported in Variable 401 - MCD Provider Tax Cost. A state may separately report the Medicaid portion of the cost of a provider assessment/tax only when it is using a cost based methodology to calculate the UPL. A state may not include this cost when calculating a DRG or Payment based UPL demonstration.

FAQ ID:92366

CMS understands that many managed care contracts include a general provision that incorporates changes in federal law during the course of the contract term. Amendments to approved contracts, or contracts under CMS review, for the purpose of updating regulatory citations is not necessary. However, the citations will need to be updated for the next contract year. Outdated regulatory citations in contracts without such a general provision will need to be updated for the next contract year.

Supplemental Links:

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

FAQ ID:93426

No. If a state does not have a state law or policy that requires CMS approval of the contract and capitation rates prior to the effective date of the contract, the 90 day timeframe is not applicable. However, as a general matter, states should submit the contracts and rates 90 days prior to the start of the contract term. CMS intends to provide future guidance on the prior approval requirements as a condition of claiming FFP in section 438.806, which are distinct from the requirements at section 438.3(a).

Supplemental Links:

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

FAQ ID:93431

There is a technical error in section 438.210(a)(2) as the cross-reference should have incorporated subpart B of part 441 rather than subpart B of part 440. All Medicaid beneficiaries under age 21 are entitled to EPSDT services, whether they are enrolled in a managed care plan or they are in fee-for-service. Under section 1905(r) of the Social Security Act (the Act), EPSDT services must include ""[s]uch other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and physical and mental illness and conditions discovered by the screening services, whether or not such services are covered under the State plan."" CMS intends to issue a regulatory correction to address this error. We also want to remind readers that sections 1902(a)(43) and 1905(r)(5) of the Act are applicable to the provision of EPSDT, despite not being expressly incorporated in part 441. Detailed guidance on EPSDT can be found in ""EPSDT"" A Guide for States: Coverage in the Medicaid benefit for Children and Adolescents, June 2014, available at https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf (PDF, 613.1 KB).

Supplemental Links:

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

FAQ ID:93436