CMS Pub. 100-16, ch. 7, § 70.4.3

From 2006 through 2010, the Part D risk adjustment model used a multiplier to adjust

risk scores when the beneficiary enrolled in the Part D plan had Long Term Institutional

status. Starting in 2011, the Part D risk adjustment model no longer uses multipliers and

instead uses a separate risk score for beneficiaries who have LTI status. Regardless of

payment year and risk model used, the Part D risk adjustment model will consider a

beneficiary’s LTI status in the payment year, not the data collection year; this approach

more accurately reflects treatment patterns upon which costs are based.

CMS uses information from the Minimum Data Set (MDS), collected routinely from

nursing homes, to identify the population of long-term institutionalized. MDS

assessments are sent to CMS on at least a quarterly basis. CMS uses the presence of a

90-day assessment to identify the long-term residents for payment purposes. Payment

using a long term institutional risk score will begin at the start of the month following the

90-day assessment. Once persons are so identified, they remain in long-term status until

discharged to the community for more than fourteen days. The costs of the short term

institutionalized (less than 90 days) are recognized in the community model.

At the final payment reconciliation that takes place post-contract year, CMS uses each

beneficiary’s actual month-by-month LTI status in the payment year to determine which

risk score or multiplier to apply. Because CMS calculates initial and mid-year risk scores

before it has complete data on beneficiaries’ LTI status in the payment year, it uses the

presence of a 90-day assessment reported for any one month during the 12-month data

collection period as a proxy for LTI in the payment year.

MMR fields specific to LTI status.

• RA Factor Type Code (field 47; positions 189-90) – A value of "I" means that the

enrollee has been institutionalized 90+ days as of the payment month.

• Part D Long Term Institutional Indicator (field 70; position 325) - Values are A

(aged), D (disabled), or blank. The enrollee has been in an institution for 90+

days as of the payment month. The Part D LTI multiplier is applied on a

concurrent basis and based on the person’s current Medicare entitlement status

(aged, or disabled). For example, “LTI Aged” means that an Aged (65+)

beneficiary has a 90+ day assessment during the month that the LTI Aged

multiplier was applied for payment.