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, for the LTSS Comprehensive Care Plan and Update measure, the care plan does not have to take place in the member’s home. However, it must be done face-to-face unless certain exceptions are met. These exceptions include circumstances in which:

• The member was offered a face-to-face discussion and refused (either refused a face-to-face encounter or requested a telephone discussion instead of a face-to-face discussion).
• The state policy, regulation, or other state guidance excludes the member from a requirement for face-to-face discussion of a care plan.

FAQ ID:89146

Use the most recently updated care plan.

FAQ ID:89151

To meet the LTSS Comprehensive Care Plan and Update measure numerator, the care plan must be signed by the member, unless the care plan is under appeal in the specified timeframe, and there is documentation that the care plan was in appeal. There is an exclusion for members who refuse to take part in care planning. This exclusion is reported with the measure rate, so the overall measure rate can be interpreted correctly. For example, a plan that is not successful at engaging members in care planning, indicated by a high exclusion rate, would suggest the overall rate on the measure should be interpreted with caution.

FAQ ID:89166

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

FAQ ID:89176

In these circumstances, MLTSS plan records should clearly document that no caregiver was involved to satisfy the measure criteria. For example, there are situations in which it may not be appropriate to engage the caregiver, including cases in which the member refused to involve the caregiver, or the invited caregiver declined to participate. Reasons for lack of caregiver involvement are not required; documentation that a caregiver was not involved suffices.

FAQ ID:89181

For certain elements of the care plan, documentation of no deficit suffices to receive credit for the elements (for example, functional needs, medical needs, cognitive impairment needs). Other elements in the core and supplemental rates of the Managed Long Term Services and Supports (MLTSS) LTSS Comprehensive Care Plan and Update measure require documentation regardless of whether a deficit is identified (for example, individualized member goal, plan for follow-up and communication, plan for emergency). Refer to the details in the measure specification to identify where documentation of no deficit meets the element definition.

FAQ ID:89196

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

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

State laws determine what information is required of the health plans. A health plan's disclosure and use of information that is required to be submitted under state law - such as, information from insurer eligibility files sufficient to determine during what period any individual may be, or have been, covered by a health insurer and the nature of the coverage that is or was provided by the health insurer — is consistent with the HIPAA privacy provisions.

Under HIPAA, both the state Medicaid agency and most health insurers are covered entities and must comply with the HIPAA Privacy Rule in 45 CFR Part 160 and Part 164, Subparts A and E. In their capacities as covered entities under HIPAA, the state Medicaid agency and health insurers are restricted from using and disclosing protected health information (PHI), as that term is defined in 45 CFR section 160.103, other than as permitted or required by the HIPAA Privacy Rule. However, as relevant here:

1. A covered entity may use or disclose PHI to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. (45 CFR 164.512(a)(1)) Under this provision, each covered entity must be limited to disclosing or using only the PHI necessary to meet the requirements of the law that compels the use or disclosure. Anything required to be disclosed by a law can be disclosed without violating HIPAA under the "required by law" provisions. Therefore, health insurers may disclose data elements in addition to the four minimum data elements, up to and including submission of an entire insurer eligibility file, to the extent such information is required to be submitted by state law. (45 CFR 164.512(a))
2. Separately, a covered entity may use or disclose PHI, without the consent of an individual, for payment activities, including to facilitate payment. (45 CFR 164.502(a)(1) and 164.506) Under HIPAA, the term payment includes activities undertaken by a health plan to determine or fulfill its responsibility for coverage and provision of benefits under the health plan. These activities include determinations of eligibility or coverage, adjudication or subrogation of health benefits claims, and collection activities. (45 CFR 164.501) To the extent plans are releasing this information to the Medicaid program for payment purposes; this is a separate basis for disclosure under HIPAA.
3. The HIPAA Privacy Rule generally requires covered entities to take reasonable steps to limit the use and disclosure of PHI to the minimum necessary to accomplish the intended purpose. (45 CFR 164.502(b)(1)) However, among other limited exceptions, the minimum necessary requirements do not apply to uses or disclosures that are required by law under 45 CFR 164.512(a).

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB)

FAQ ID:91216