Frequently Asked Questions

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.

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).

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.

No. Although a comprehensive assessment may include falls risk assessment elements, this measure does not require the risk assessment elements to be documented as part of a comprehensive assessment. For this measure, a falls risk assessment is considered complete if the member record includes any documentation of a balance/gait assessment, and documentation of assessment of postural blood pressure, vision, home fall hazards, and/or medications.

No, the components can be completed during separate encounters, provided they are documented in the member record as having been performed between August 1 of the year prior to the measurement year and December 31 of the measurement year.

No, a standardized tool is not required, although documentation of use of a standardized tool (for example, Get Up & Go, Berg, Tinetti) would meet the balance/gait assessment component of the measure.

Yes, the same tool may be used to conduct the screening and risk assessment for the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure.

No. Although a comprehensive care plan may include the elements comprising a plan of care to prevent future falls, the measure does not require the plan of care elements to be documented as part of a comprehensive care plan. For this measure, a plan of care is considered complete if the member record includes any documentation of exercise therapy or referral to exercise between August 1 of the year prior to the measurement year and December 31 of the measurement year.

Yes, the rate of exclusion for members who refused an assessment and/or a plan of care needs to be reported with the measure’s performance rate.

No, the sample for Part 2 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measure is different from the systematic sample used for the LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, LTSS Shared Care Plan with Primary Care Practitioner, and Part 1 of the Screening, Risk Assessment, and Plan of Care to Prevent Future Falls measures. Members included in the sample for Part 2 of this measure must have a documented history of falls (at least two falls or one fall with injury in the past year), including documentation of plan member self-reported history of falls.