Frequently Asked Questions

The following measures assess institutional rebalancing and utilization:

• LTSS Admission to an Institution from the Community
• LTSS Minimizing Institutional Length of Stay
• LTSS Successful Transition after Long-Term Institutional Stay

FAQ ID:91101

Yes. Value sets are the complete set of procedure and codes used to identify a service or condition included in a measure. All three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay—use the "Institutional Facility"value set (XLSX, 2.88 MB). 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:91106

No, include paid claims only (days denied for any reason should not be included) for all three of the rebalancing measures—LTSS Admission to an Institution from the Community, LTSS Minimizing Institutional Length of Stay, and LTSS Successful Transition after Long-Term Institutional Stay.

FAQ ID:91111

No; discharges for planned hospital admissions are excluded from the measure denominator. Identify planned discharges using the value sets (XLSX, 2.88 MB).

FAQ ID:89236

Yes, both the re-assessment and the care plan must include each of the nine specified core elements. The re-assessment and care plan must be done face-to-face unless there is documentation that the member refused a face-to-face encounter.

FAQ ID:89241

The denominator for the Reassessment/Care Plan Update after Inpatient Discharge measure is identified through administrative claims for inpatient discharges. Managed care plans that are not the primary payer for inpatient care, which is usually covered under a medical benefit, do not routinely have reliable access to administrative claims for inpatient stays to identify individuals who are eligible to be counted in the measure denominator. Therefore, the eligible population for this measure is restricted to individuals who receive both medical and LTSS benefits through the managed care plan providing MLTSS.

FAQ ID:89246

If MLTSS plans can obtain timely, complete, and accurate inpatient claims data for their members, then a state may choose to deviate from the measure specifications to require MLTSS plans not providing medical benefits report this measure. For example, because the timely transfer of information between hospitals and MLTSS plans is key to ensuring smooth transfers between settings of care, MLTSS plans may have access to hospital discharge data through state or regional health information exchanges. In some cases, MLTSS plans are working closely with hospitals to share timely information about admissions and discharges. In addition, some states have the data and capacity to construct this measure for MLTSS plans using Medicare claims data for Medicare- Medicaid dual eligible beneficiaries (see more information about state access to Medicare claims data).

FAQ ID:89251

A reassessment with the member after they have been discharged from an inpatient facility is required to determine whether a member has had a change (or no change) in their LTSS needs. Even if the reassessment conducted post-discharge finds no change in a member’s LTSS needs, the second rate for this measure (Reassessment and Care Plan Update after Inpatient Discharge), Managed Long Term Services and Supports (MLTSS) plan care managers should conduct a care plan update and document that they considered each of the nine core elements of the care plan, and determined that the plan of care for each element remains the same; documentation of “no changes” in the care plan as a whole does not meet the numerator criteria.

FAQ ID:89256

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