Preprint with track changes from the 60-day FR to the 30-day FR

State Plan Preprint for Integrated Care Programs

New Section: Integration of Medicare and Medicaid through Contracts with Special Needs Plans (SNPs)

(Complete for each individual Integrated Care SNP Program.)

A. Name and General Description of the Program:

________________________________________________________________

________________________________________________________________

________________________________________________________________

Please note that the State Medicaid contract will outline the operational details and Medicaid covered services provided in the integrated program.

B. Authority. The state is operating its integrated program under the following authority (check all that apply):

_____ 1915(a)

_____ 1915(a)/(c)

_____ 1915(b)

____ 1915(b)(1)

____ 1915(b)(2)

____ 1915(b)(3)

____ 1915(b)(4)

_____ 1915(b)/(c)

____ 1915(b)(1)

____ 1915(b)(2)

____ 1915(b)(3)

____ 1915(b)(4)

_____ 1915(i) – Home and Community Based DRA

_____ 1932(a) State Plan Authority

_____ 1115

_____ Section 6044 of the Deficit Reduction Act (Benchmark)

_____ Other (please specify)_____________________

3. Scope of Services (check all that apply)

_____ Acute

_____ Long Term Care

_____ Other (please specify) ___________________________

3. Payment. Payment method to the contracting entity will be:

______ The State makes capitated payments to SNPs to provide ALL Medicaid benefits.

______ The State makes capitated payments to SNPs to provide all Medicaid benefits except long-term care services.

______ The State makes capitated payments to SNPs to provide some Medicaid benefits.

______ The State coordinates with SNPs to wrap ALL Medicaid benefits around the Medicare benefit package, and pays for those benefits on a fee for service basis.

______ The State coordinates with SNPs to wrap all Medicaid benefits except ­­­­­_________________________________________________.

______ The State coordinates with SNPs to wrap some Medicaid benefits around the Medicare benefit package, and pays for those services on a fee for service basis.

______ Other (please specify)

3. Geographic Area

_____ Statewide

_____ Region (Specify) _____________________________

FE. Target Dual Eligible Population

____ All individuals who are Dual Eligible

____ Subset of individuals who are Dual Eligible (please specify category of dual as specified in the SNP Application)

GF. Enrollment (Check all that apply)

1. Enrollment Form

_____ The Medicaid agency utilizes or intends to utilize an integrated enrollment form for managed care.

_____ The Medicaid agency utilizes a separate enrollment form for managed care.

2. Effective Date

_____ The Medicaid and Medicare effective enrollment dates will match and comply with MA regulations in 42CFR 422.62, 422.66(a) and 422.68.

_____ The State does not coordinate Medicaid managed care enrollment date with Medicare.

3. Identification Card

_____ The Medicaid agency has elected to use a single identification card for Medicaid, Medicare, and Part D eligibility/coverage.

4. Continued Deemed Eligibility for Medicare Advantage Enrollment

_____ When an enrollee no longer meets the Medicaid eligibility criteria, but can reasonably be expected to again meet the criteria within a 6-month period, the State requires via its contract with the SNP to retain coverage for a minimum period of ____________________________.

5. Authorized Representative

_____ The Medicaid agency or its designee will allow as an authorized representative to enroll Medicaid beneficiaries in a SNP.

HG. Marketing

Integrated Marketing Materials

_____ The Medicaid agency elects to utilize or intends to utilize integrated marketing materials and coordinate a joint review process with CMS.

I. Grievance and Appeals

_____ The Medicaid agency intends to utilize an integrated grievance and appeals process.

JH. Quality Assurance

Integrated Reporting

_____ The State Medicaid agency integrates its reporting requirements with the Medicare Advantage requirements. The State requires integrated SNPs to submit (check all that apply):

_____ Healthcare Effectiveness Data and Information Set Employer Data and Information Set (HEDIS) – Plan level

_____ Consumer Assessment of Healthcare Providers and Systems (CAHPS)

_____ Health Outcome Survey– Plan level

Integrated Performance Improvement Projects

_____ The State integrates the Medicaid Performance Improvement Program requirements (42CFR 438.240) with the Medicare Quality Improvement Program requirements (42CFR 422.152.

_____ Other

KI. Assurances

Place a check mark to confirm compliance with the following:

______ The State assures compliance with all applicable Federal laws and regulations governing the operation of their program; e.g., grievance and appeals, access, and beneficiary rights and protections.

______ The State assures that evidence of State relationship with SNP will be provided to CMS as required in the Medicare SNP application and within the prescribed timeframes.

______­ The State assures contracts for services under the state plan will be submitted to CMS Regional Office for review consistent with CMS regulatory requirements and policy.