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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

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Care managers often do not document data elements in the assessment and care plan measures unless the member has "a problem." For example, they may not document that they assessed the member's vision or need for an assistive device if no problem was identified. How can states or plans address this issue?

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

Which are the Managed Long Term Services and Supports (MLTSS) assessment and care planning measures?

The MLTSS assessment and care planning measures include:

  • LTSS Comprehensive Assessment and Update
  • LTSS Comprehensive Care Plan and Update
  • LTSS Shared Care Plan with Primary Care Practitioner(PCP)
  • LTSS Reassessment/Care Plan Update after Inpatient Discharge
  • Screening, Risk Assessment, and Plan of Care to Prevent Future Falls: Falls Part 1 (Screening) and Falls Part 2 (Risk Assessment and Plan of Care)

FAQ ID:89066

Should states require plans to report both the core and supplemental rates for the Managed Long Term Services and Supports (MLTSS) LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update measures, and LTSS Reassessment/Care Plan Update After Inpatient Discharge measures?

It is recommended that MLTSS plans report both rates. However, if the state believes there are valid reasons for not reporting both rates, such as costly changes in assessment and care planning forms and information technology systems, it might consider phasing in the supplemental rates over time. For instance, in the first year of measure use (for example, measurement year 2018), the state could require MLTSS plans to report just the core rate, and then require that MLTSS plans report both core and supplemental rates for measurement year 2019 or 2020. Although they are called "supplemental rates," they are still very important, and should be viewed as "aspirational." MLTSS plans should strive to cover more assessment and care plan elements over time.

FAQ ID:89071

Do I need value sets to calculate any of the five the Managed Long Term Services and Supports (MLTSS) assessment and care planning measures? If so, where can I find the value sets?

Value sets are the complete set of procedure and diagnostic codes used to identify a service or condition included in a measure. One of the assessment and care planning measures—LTSS Reassessment/Care Plan Update after Inpatient Discharge—uses value sets to identify potentially planned hospitalizations. Please see "Do I need to use value sets to calculate these measures? If so, where can I find the value sets?" for more information regarding using value sets for the three institutional rebalancing and utilization measures.

View the value sets (XLSX, 2.88 MB). Please 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:89076

Can I use the same sample for the Managed Long Term Services and Supports (MLTSS) Part 1 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure as the LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, LTSS Shared Care Plan with Primary Care Practitioner, and LTSS Reassessment/Care Plan Update after Inpatient Discharge measures?

Yes, the same sample can be used for Part 1 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure as the LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, and LTSS Shared Care Plan with Primary Care Practitioner measures.

FAQ ID:89081

Will states need to modify already approved contracts to add the final capitation rates to the contract to comply with section 438.3(c), which requires that the payment term be included in the contract?

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.

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FAQ ID:93171

A number of provisions in the Final Rule were not subject to substantive changes but were redesignated in a new section in 42 CFR part 438 and have an implementation date of July 5, 2016. Will states be required to amend regulatory citations in approved contracts or contracts currently under CMS review?

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.

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FAQ ID:93426

Do all states need to submit contracts and rate certifications to CMS 90 days prior to the effective date of the contract pursuant to section 438.3(a)?

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).

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FAQ ID:93431

It appears that section 438.210(a)(2), which addresses the amount, duration, and scope of Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT) under managed care, incorrectly cross-references "subpart B of part 440" rather than "subpart B of part 441." In addition, the Omnibus Budget Reconciliation Act of 1989 broadened the statutory requirements for EPSDT beyond those reflected in 42 CFR part 441. Please clarify how this error will be addressed.

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).

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FAQ ID:93436

Does the requirement in section 438.4(b)(5) that payments from any rate cell must not cross-subsidize or be cross-subsidized by payments for any other rate cell mean that the actuary must use assumptions that are unique to each rate cell?

No. CMS addressed this provision at page 27569 of the Final Rule. Section 438.4(b)(5) does not require there to be different assumptions (such as trend or age, gender, or regional rating) for each rate cell and does not prevent the use of the same assumptions across more than one rate cell. The prohibition on cross-subsidization among rate cells under the contact is to ensure prudent fiscal management and that the capitation rate for each rate cell is independently actuarially sound.

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FAQ ID:93441

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