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
Should I include discharges resulting in readmission to the institution in the Long Term Services and Supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?
No, discharges that result in readmission to the institution within 60 days of discharge from the institution do not meet the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator criteria.
FAQ ID:91146
SHARE URLWhen counting the duration of a member's stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator calculation, should I include the day of discharge?
Do not count the day of discharge unless the member’s admission and discharge occurred on the same day. If the admission and discharge occurred on the same day, the number of days in the stay is equal to one.
FAQ ID:91156
SHARE URLIf there is no discharge, how should I calculate the length of stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?
If there is no discharge, calculate the length of stay as the date of the last day of the measurement year minus the institutional facility admission date.
FAQ ID:91166
SHARE URLAre the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measures risk-adjusted?
Yes, the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long- Term Institutional Stay measures are risk-adjusted based on the members’ dual eligibility status, age and gender, diagnoses from the institutional facility admission, and number of hospital stays and months of enrollment in the classification period. See the risk adjustment weights needed for these measures are in the risk adjustment tables (XLSX, 59.69 KB).
FAQ ID:91171
SHARE URLShould a member's admission be included in the Long Term Services and Supports (LTSS) Successful Transition after Long-Term Institutional Stay measure denominator if it was a direct transfer from another institution?
No, do not include these admissions in the LTSS Successful Transition after Long-Term Institutional Stay measure denominator.
FAQ ID:91176
SHARE URLWhen a facility has been in operation for the dates of service covered by the Upper Payment Limit (UPL) demonstration, can a state demonstrate the UPL by using less than 12 months of data?
In accordance with Medicare cost reporting, the state must use 12 months of cost data reported by each facility. With regard to payment data, the state should use actual amounts, to the extent available, then calculate a claims completion factor based on historic utilization. The state’s UPL submission must include an explanation of its methodology to estimate payments. The use of a claims completion factor provides a reasonable estimate of the amount that Medicare would pay for these services, consistent with the UPL as defined at 42 CFR 447.272.
FAQ ID:92446
SHARE URLWhat data should my state provide to the Centers for Medicare & Medicaid Services (CMS) for the annual Upper Payment Limit demonstrations?
Effective state fiscal year 2020, each state must submit a complete data set of payments to Medicaid providers, including providers paid at cost, as well as critical access hospitals. This would require states to submit cost and payment data to CMS that previously was not requested.
FAQ ID:92456
SHARE URLHow will the Centers for Medicare & Medicaid Services (CMS) disseminate the list of Healthcare Common Procedure Coding System (HCPCS) codes subject to the federal financial participation (FFP) limit each year?
Annually, CMS will request a list of covered durable medical equipment HCPCS codes from the Medicare Pricing, Data Analysis and Coding Contractor. Once the list is received, CMS will distribute the list through the CMS Regional Office Associate Regional Administrator.
FAQ ID:93671
SHARE URLStates have raised concerns around the federal financial participation (FFP) limit demonstration due date because they may not have received all durable medical equipment (DME) claims from providers at the point demonstrations are due. How may a state ensure compliance with the FFP limit without allowing for a claims run-out period.
To address claims run-out and ensure compliance with the FFP limit, we recommend states with these concerns conduct interim FFP limit demonstrations for DME no later than three months after the end of the calendar year for the previous calendar year (that is, January 1-December 31). The interim DME FFP limit demonstration will be due by March 31 of each calendar year and will contain data for the period of January 1 to December 31 of the preceding year. The final demonstration would be due one year later on March 31 and include all claims received during the run-out period dates of service within the interim demonstration period. The interim demonstration process should provide states with an understanding of potential violations of the FFP to make any necessary budgeting and rate changes. This method is being used to allow provide for a reasonable claims run out period as allowed under 42 CFR 424.44, which states that claims must be filed no later than one calendar year after the date of service.
FAQ ID:93676
SHARE URLCan you explain the difference between a prospective Upper Payment Limit (UPL) and a retrospective UPL?
The difference between a prospective and retrospective UPL is in the relationship between the UPL demonstration period and the date when the UPL is submitted. For a UPL demonstration period of 7/1/2018 to 6/30/2019, a UPL is considered retrospective when it is submitted on or after the start of the demonstration period (on or after 7/1/2018). Using the same UPL demonstration period (7/1/2018 to 6/30/2019), a UPL is considered prospective if it is submitted prior to 7/1/2018.
FAQ ID:92431
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