Frequently Asked Questions

There must be documentation of the refusal, which would result in exclusion from the measure. The rate of exclusion due to a member refusing to participate should be reported along with the measure performance rate.

FAQ ID:89156

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

As a process measure, it is not designed to address the outcome of care planning—whether the services authorized by MLTSS plans and specified in the care plan meet members’ goals. One way to evaluate this outcome is through person-reported outcome measures reported through a survey or another method that asks individuals about their perspective on their care. Other measures and indicators, including those derived from the Consumer Assessment of Healthcare Providers and Systems Home and Community Based Experience of Care Survey and the National Core Indicators Aging and Disability Survey, can be used to help inform whether the services provided help individuals meet their goals.

FAQ ID:89191

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

Yes, the denominator for this measure includes all MLTSS members with a care plan meeting the criteria outlined in the LTSS Comprehensive Care Plan and Update measure core rate.

FAQ ID:89201

A PCP is a physician, non-physician (for example, nurse practitioner, physician assistant), or group of providers who offers primary care medical services. However, a care plan can be shared with a medical care practitioner other than the PCP if the practitioner is identified by the member as the primary point of contact for their medical care. Therefore, any medical care practitioner identified by the member as the primary point of contact for their medical care is considered their PCP for the purpose of calculating the measure.

FAQ ID:89206

The care plan is shared with the PCP to promote coordination of medical and LTSS services.

FAQ ID:89211

The measure specifications allow sharing the care plan by mail, fax, secure email, or mutual access to an electronic portal or Electronic Health Record. Members who refuse to share their care plan are excluded from the measure denominator, but there must be documentation in the record that the member refused to share the care plan (noting verbal refusal suffices). The rate of exclusion due to a member refusing to share their care plan with the PCP should also be reported along with the measure performance rate.

FAQ ID:89216