Frequently Asked Questions

The measures are intended for any MLTSS plan that covers Medicaid LTSS benefits. Federal regulations pertaining to 1915(c) waivers require person-centered service plans,¹ but states can decide whether to require MLTSS plans participating in a state program operating under 1915(c) authority report these measures, and if they do, states can specify which types of plans and eligible members to which the measures apply.

¹"In accordance with 42 CFR §441.301 (b)(1)(i), all waiver services must be furnished pursuant to a written service plan that is developed for each waiver participant." (1915c waiver application, Instructions, Technical Guide and Review Criteria, Appendix D-1: Service Plan Development, CMCS, DEHPG, November 2014.

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)

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.

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. 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.

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.

Yes, the assessment for the LTSS Comprehensive Assessment and Update measure is required to take place in the member’s home as a face-to-face discussion unless certain exceptions are met. These exceptions include circumstances in which:

• The member was offered an in-home assessment and refused the in-home assessment (either refused to allow the care manager into the home or requested a telephone assessment instead of an in-home assessment).
• The member is residing in an acute or post-acute care facility (hospital, skilled nursing facility, other post-acute care facility) during the assessment time period.
• The state policy, regulation, or other state guidance excludes the member from a requirement for in-home assessment.

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 also be reported along with the measure performance rate.

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

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.

Use the most recently updated care plan.