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)

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.

Four of the eight measures (LTSS Comprehensive Assessment and Update, LTSS Comprehensive Care Plan and Update, LTSS Shared Care Plan with Primary Care Practitioner (PCP), and Screening, Risk Assessment, and Plan of Care to Prevent Future Falls) apply to all members receiving a LTSS benefit through the MLTSS plan regardless of whether the MLTSS plan covers their medical care benefit.

If MLTSS plans report measure rates directly to the state, the state should conduct an independent review of a sample of members included in the reported measures, for example, by the External Quality Review Organization or state-employed abstractors.

Through our discussions with MLTSS plans, we learned that plans—particularly those operating in multiple states—can ease the burden of data collection by mapping their existing assessment and care plan tools to the standardized data elements and terminology in these measures, which would make it easier to abstract data and standardize the data collection process.

No, CMS does not require states or MLTSS plans to report these measures. However, states may choose to require plans to report any of these measures to the state Medicaid agency.

As more states shift to MLTSS and gain more experience, the need to measure program outcomes and quality has increased. The new quality measures, which were carefully designed for beneficiaries enrolled in MLTSS plans, represent a major step forward in giving the Centers for Medicare & Medicaid Services (CMS), states, MLTSS plans, providers, and consumers the ability to compare the performance of MLTSS programs and plans within and across states.

If you have additional questions about these measures, please submit your question to the technical assistance mailbox at MLTSSmeasures@cms.hhs.gov for assistance.

The technical specifications and webinar materials for these measures are available on the MLTSS page:

A falls screening is an evaluation of whether a Managed Long Term Services and Supports plan member has experienced a history of falls and/or problems with balance or gait. A falls risk assessment includes a balance/gait assessment and one other assessment component and should only be performed for members with a documented history of falls (at least two falls or one fall with injury in the past year).