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
No. MLTSS plans are not required to share the full care plan with the PCP or other documented medical care practitioner. MLTSS plans may choose which parts of the care plan are most relevant to the practitioner.
No, the LTSS Shared Care Plan with Primary Care Practitioner (PCP) measure only looks to see that a care plan was sent to a primary care practitioner (PCP) by the MLTSS plan. No signature from the PCP is necessary to count towards the numerator of this measure.
There is no need for a release of information. If a member gives the plan the contact information for their PCP, the plan can share information with that PCP. Plans or other providers of LTSS should try to coordinate LTSS services with medical services, even if they are not the primary payer for medical services for the member. Plans that do not know the member’s PCP can/should ask the member to identify their PCP and request their contact information. The measure is intended to determine whether plans tried to connect with the medical care provider. There is an exclusion in this measure for members who refuse to have their care plan shared with the PCP, so if the member refuses, this should be documented, and such members are excluded from the measure rate.
No; discharges for planned hospital admissions are excluded from the measure denominator. Identify planned discharges using the value sets.
Yes, both the re-assessment and the care plan must include each of the nine specified core elements. The re-assessment and care plan must be done face-to-face unless there is documentation that the member refused a face-to-face encounter.
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.
As reconfigured under the final regulation of July 5, 2017, MEQC will work in conjunction with the Payment Error Rate Measurement (PERM) program. In those years when states undergo their triennial PERM reviews, the states will not conduct MEQC pilots. The latter will only be required in the two off-years between PERM review years. CMS has restructured the MEQC program so that it more effectively complements the PERM program and provides states with the necessary flexibility and opportunity to target specific problems or high-interest areas during the two off-years of the PERM cycle.
The MEQC requirements on active case reviews generally mirror the requirements of the eligibility component of PERM reviews. The regulation requires that states perform reviews of a sample of active Medicaid and Children’s Health Insurance Program (CHIP) cases to identify new eligibility approvals and renewals that were made in error. As in PERM, states will be required to submit case-level reports on the sampled cases they review and corrective action plans that describe steps taken to remediate the errors found.
However, in contrast to PERM, when states identify errors in their active Medicaid and CHIP cases, they will be required to undertake a payment review. This will consist of a review of all claims paid over the first three months after an erroneous eligibility determination was made, and a summary of the overstated or understated liability. States will in turn be required to submit adjustments to the amount of federal financial participation (FFP) claimed through the CMS-64 reporting process for Medicaid and the CMS-21 reporting process for CHIP. The adjustments are required for identified claims in which too much or too little FFP was received. There is no payment review or re-crediting requirement in PERM, although disallowance of FFP can be taken in states whose PERM error rate exceeds the national threshold of 3% based on a formula described at 42 CFR 431.1010. MEQC contains no such disallowance provision.
The MEQC program also contains one other significant element that is not found in PERM. Besides the requirement that states review at least 400 cases in their active case universe (including a minimum of 200 cases), MEQC requires states to review at least 400 negative case actions. At least 200 of these must be Medicaid and 200 must be CHIP. Negative case actions involve erroneous denials of Medicaid or CHIP eligibility or erroneous terminations from Medicaid or CHIP. This is an area with no PERM counterpart in which states will be developing case-level reporting and corrective actions. Negative case action reviews will not be triggered by PERM findings. Largely for this reason, the regulation requires that states pull their sample of these from the entire Medicaid and CHIP universe of cases. By sampling from the full range of Medicaid and CHIP cases, states should be able to obtain an overview of those sectors in their programs that may be especially vulnerable to improper denials or terminations.