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.
Frequently Asked Questions
Both the State Medicaid Director Letter describing the Substance Use Disorder (SUD) section 1115 demonstration opportunity and the Centers for Medicare & Medicaid Services (CMS) SUD Implementation Plan template, reference needs assessment tools and program standards established by the American Society for Addiction Medicine (ASAM). Is a state required to reference or rely on the ASAM Criteria in implementing an SUD section 1115 demonstration?
No, a state is not required to reference or rely on the ASAM Criteria however, states should use guidelines/patient placement tools that are comparable to ASAM criteria. The State Medicaid Director Letter describing the SUD section 1115 demonstration opportunity references the ASAM Criteria as a recognized standard and an example of a patient placement assessment tool that states could use. Participating states are expected to ensure that providers use an SUD-specific, multi-dimensional assessment tool in determining the types of treatments and level of care a beneficiary with an SUD may need. The ASAM Criteria is referenced as a representative example of such an assessment tool.
Some states proposed alternative needs assessment tools. CMS reviews each alternative proposal on an individual basis, and CMS has so far determined that those alternatives are comparable to the ASAM Criteria and meet the expectations for this demonstration initiative. In addition, participating states are expected to implement provider qualifications for residential treatment providers that reflect well-established standards for these treatment settings. Again, the ASAM Criteria is referenced as an example of a resource that states may use for determining those standards.
Are there exclusions for the Long Term Services and Supports Admission to an Institution from the Community measure's eligible population (denominator)?
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.
Are there exclusions for the Long Term Services and Supports Admission to an Institution from the Community measure's numerator?
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.
Can the community residence include assisted living?
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.
Is the Long Term Services and Supports Admission to an Institution from the Community measure risk-adjusted?
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).
Are states only required to conduct Upper Payment Limit (UPL) demonstrations for services with approved state plan supplemental payment methodologies?
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.
How and when should the Medicaid hospital tax/provider assessment be included in the inpatient hospital template?
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.