Long Term Services & Supports (LTSS)
How this system supports the Medicaid Program
Medicaid is the primary payer across the nation for long-term care services. Medicaid allows for the coverage of these services through several vehicles and over a continuum of settings, ranging from institutional care to community-based long-term services and supports (LTSS). LTSS systems support the management of these services.
CMS-Required Outcomes
Each CMS-Required outcome is based on statutory or regulatory requirements. CMS-Required Outcomes and Metrics are used to demonstrate that a system is compliant with the applicable federal regulations which pertain to that specific system or module. CMS-Required outcomes form the baseline for system/module functionality, which must continue to receive enhanced federal funding for operations.
| Reference # | CMS Required Outcomes | Default Metrics | Regulatory Sources |
|---|---|---|---|
| LTSS1 | LTSS system generates notifications including eligibility determination; termination of state waiver (30 days in advance); and inspections taking place in a beneficiary's home when a beneficiary receives services in his/her own home or the home of a relative (HCBS waiver for individuals 65 and older) (48 hours in advance). | - Percent of notifications and decisions sent to the correct individuals within the required timeframe. |
42 CFR 441.307
42 CFR 441.356 42 CFR 441.365 42 CFR 431.206 42 CFR 431.210 |
| LTSS2 | LTSS systems stores proof of beneficiary consent to enroll in HCBS state plan or waiver-based programs. | - Percentage of beneficiaries with proof of consent stored in system | 42 CFR 441.301 |
| LTSS3 | LTSS system assigns, tracks and changes beneficiary prioritization and waiver waitlist status. |
- Verify assigning and changing of beneficiary prioritization.
- Verify assigning and changing waitlist status. - Verify researching and finding prioritization and waitlist status. - Verify ability to report on waitlist and prioritization status. | 42 CFR 441.305 |
| LTSS4 | LTSS system maintains a record of beneficiaries who have left the waiver program due to death or loss of eligibility for Medicaid under the State Plan to replace those beneficiaries with others on the waitlist. |
- Verify ability to update beneficiary records for death, loss of eligibility
– Pass/Fail | 42 CFR 441.305 |
| LTSS5 | LTSS system stores the person-centered plan, including any updates or changes containing all required information and consent signatures. | - Percentage of beneficiaries with current and complete person-centered plan | 42 CFR 441.302 |
| LTSS6 | LTSS system supports conflict-free case management via role-based access, proper firewalls, and mitigation strategies that provide beneficiaries appropriate access to records. |
- Pass/Fail for the following:
- Verify that only correctly assigned/authorized logins can view care plans. - Verify that 'not authorized logins' are unable to view plans. - Verify that 'not authorized logins' cannot update or change data. |
HIPAA
42 CFR 441.301 |
| LTSS7 | LTSS System supports completion of CMS Form 372. | - Timeliness of reporting to CMS |
42 CFR 433.112
42 CFR 441.302 |
| LTSS8 | LTSS system collects and saves prior authorizations to exchange with MMIS as needed to prevent the provision of unnecessary or inappropriate services and supports. |
- Pass/Fail for the following:
- Verify the capability to save and track prior authorization information on LTSS beneficiaries. - Verify capability to send/exchange prior authorization data to required interfaces. | 42 CFR 441.301 |
| LTSS9 | LTSS system documents and tracks reportable events related but not limited to instances of abuse, neglect, exploitation, and unexplained death from case initiation to case closeout. |
- Average number of days it takes from a critical incident to completion of an administrative review
- Pass/Fail for the following: - Verify capability to receive reportable events from various media such as phone, tablet, text message, online. - Verify capability to track reportable events through to closure. - Verify capability to search for and view a reportable event using information such as beneficiary name and/or date of reportable event. |
42 CFR 441.404
CMS Bulletin, Modifications to Quality Measures and Reporting in §1915(c) Home and Community-Based Waivers, March 12, 2014 42 CFR 441.585 and 42 CFR Part 438 |
| LTSS10 | LTSS system collects grievances related but not limited to instances of abuse, neglect, exploitation, and unexplained death from case initiation to case closeout. |
- Average number of days it takes from a grievance reported to completion of an administrative review.
- Pass/Fail for the following: - Verify capability to receive grievances from various media such as phone, tablet, text message, online (per state-specified requirements). - Verify capability to collect grievance data required for audits/hearings. - Verify capability to track grievances through closure. - Verify capability to search for and view a grievance by using information such as beneficiary name and/or date of reportable event. | 42 CFR 441.464; 441.555 |
| LTSS11 | LTSS system creates trend reports of critical incident causes and tracks trends of critical incidents after operational implementation of interventions/mitigations/corrective actions. | - Trend data of critical incidents. |
Application for a §1915(c) Home and Community-Based Waiver [Version 3.6, January 2019]
Instructions, Technical Guide and Review Criteria p.242-243 (Appendix G-1-e) Modifications to Quality Measures and Reporting in §1915(c) Home and Community-Based Waivers, Page 10 |
State-Specific Outcomes - CMS Approved
States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.
When drafting state-specific outcomes statements, keep these tips in mind.
Examples for Long Term Services & Supports
We are actively gathering and evaluating outcomes statements crafted by states for this business area.
Please send examples from your state that you’d like to share to MESCertificationRepo@cms.hhs.gov. Our team will collect and share the best examples.
| State | Medicaid Program Goal | Outcome Statement | Metric(s) |
|---|---|---|---|