Form CMS-10120 1932a SPA Preprint

CMS-PM-10120
Date: XXX, 2014

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1932(a)(1)(A)

A.

Section 1932(a)(1)(A) of the Social Security Act.
The State of _______________ enrolls Medicaid beneficiaries on a mandatory basis
into managed care entities (managed care organization (MCOs) and/or primary care
case managers (PCCMs)) in the absence of section 1115 or section 1915(b) waiver
authority. This authority is granted under section 1932(a)(1)(A) of the Social
Security Act (the Act). Under this authority, a state can amend its Medicaid state
plan to require certain categories of Medicaid beneficiaries to enroll in managed
care entities without being out of compliance with provisions of section 1902 of the
Act on statewideness (42 CFR 431.50), freedom of choice (42 CFR 431.51) or
comparability (42 CFR 440.230).
This authority may not be used to mandate enrollment in Prepaid Inpatient Health
Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to
mandate the enrollment of Medicaid beneficiaries described in 42 CFR 438.50(d).
Where the state’s assurance is requested in this document for compliance with a
particular requirement of 42 CFR 438 et seq., the state shall place check mark to
affirm such compliance.

1932(a)(1)(B)(i)
B.
1932(a)(1)(B)(ii)
42 CFR 438.50(b)(1)-(2)

Managed Care Delivery System.
The State will contract with the entity(ies) below and reimburse them as noted
under each entity type.
1.

☐MCO
a. ☐Capitation

2.

☐PCCM (individual practitioners)
a. ☐ Case management fee
b. ☐ Bonus/incentive payments
c. ☐ Other (please explain below)

3.

☐PCCM (entity based)
a. ☐ Case management fee
b. ☐ Bonus/incentive payments
c. ☐ Other (please explain below)

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For states that elect to pay a PCCM a bonus/incentive payment as indicated in
B.2.b. or B.3.b, place a check mark to affirm the state has met all of the
following conditions (which are representative of the risk incentive rules for
managed care contracts published in 42 CFR 438.6(c)(5)(iv)).
☐a. Incentive payments to the PCCM will not exceed 5% of the total
FFS payments for those services provided or authorized by the
PCCM for the period covered.
☐b. Incentives will be based upon a fixed period of time.
☐c. Incentives will not be renewed automatically.
☐d. Incentives will be made available to both public and private
PCCMs.
☐e. Incentives will not be conditioned on intergovernmental
transfer agreements.
☐f. Incentives will be based upon specific activities and targets.

CFR 438.50(b)(4)

C.

Public Process.
Describe the public process including tribal consultation, if applicable, utilized for
both the design of the program and its initial implementation. In addition, describe
what methods the state will use to ensure ongoing public involvement once the state
plan program has been implemented. (Example: public meeting, advisory groups.)

D. State Assurances and Compliance with the Statute and Regulations.
If applicable to the state plan, place a check mark to affirm that compliance with the
following statutes and regulations will be met.
1932(a)(1)(A)(i)(I)
1903(m)
42 CFR 438.50(c)(1)

1.

☐The state assures that all of the applicable requirements of
section 1903(m) of the Act, for MCOs and MCO contracts will be met.

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1932(a)(1)(A)(i)(I)
1905(t)
42 CFR 438.50(c)(2)
1902(a)(23)(A)

2.

☐The state assures that all the applicable requirements of section 1905(t)
of the Act for PCCMs and PCCM contracts will be met.

1932(a)(1)(A)
42 CFR 438.50(c)(3)

3.

☐The state assures that all the applicable requirements of section 1932
(including subpart (a)(1)(A)) of the Act, for the state's option to limit freedom
of choice by requiring Beneficiaries to receive their benefits through managed
care entities will be met.

1932(a)(1)(A)
42 CFR 431.51
1905(a)(4)(C)

4.

☐The state assures that all the applicable requirements of 42 CFR 431.51
regarding freedom of choice for family planning services and supplies as
defined in section 1905(a)(4)(C) will be met.

1932(a)(1)(A)

5.

☐The state assures that it appropriately identifies individuals in the
mandatory exempt groups identified in 1932(a)(1)(A)(i).

1932(a)(1)(A)
42 CFR 438
1903(m)

6.

☐The state assures that all applicable managed care requirements of
42 CFR Part 438 for MCOs and PCCMs will be met.

1932(a)(1)(A)
42 CFR 438.6(c)
42 CFR 438.50(c)(6)

7.

☐The state assures that all applicable requirements of 42 CFR 438.6(c)
for payments under any risk contracts will be met.

1932(a)(1)(A)
CFR 447.362
42 CFR 438.50(c)(6)

8.

☐The state assures that all applicable requirements of 42 CFR 447.362 for 42
payments under any non-risk contracts will be met.

45 CFR 92.36

9.

☐The state assures that all applicable requirements of 45 CFR 92.36 for
procurement of contracts will be met.

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1932(a)(1)(A)
1932(a)(2)

E. Populations and Geographic Area
1.

Population
Section 1931 Children &
Related Populations –
1905(a)(i)
Section 1931 Adults &
Related Populations1905(a)(ii)
Low-Income Adult Group
Former Foster Care Children
under age 21
Former Foster Care Children
age 21-25
Section 1925 Transitional
Medicaid age 21 and older
SSI and SSI related Blind
Adults, age 18 or older* 1905(a)(iv)
Poverty Level Pregnant
Women – 1905(a)(viii)
SSI and SSI related Blind
Children, generally under age
18 – 1905(a)(iv)
SSI and SSI related Disabled
children under age 18
SSI and SSI related Disabled
adults age 18 and older –
1905(a)(v)
SSI and SSI Related Aged
Populations age 65 or older1905(a)(iii)

Included Populations. Please check which eligibility populations are included,
if they are enrolled on a mandatory (M) or voluntary (V) basis, and the
geographic scope of enrollment. Under the geography column, please indicate
whether the nature of the population’s enrollment is on a statewide basis, or if
on less than a statewide basis, please list the applicable counties/regions.
M

Geographic Area

V

Geographic Area

Excluded

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Population
SSI Related Groups Exempt
from Mandatory Managed
Care under 1932(a)(2)(B)
Recipients Eligible for
Medicare
American Indian/Alaskan
Natives
Children under 19 who are
eligible for SSI
Children under 19 who are
eligible under Section
1902(e)(3)
Children under 19 in foster
care or other in-home
placement
Children under 19 receiving
services funded under section
501(a)(1)(D) of title V and in
accordance with 42 CFR
438.50(d)(v)
Other

M

Geographic Area

V

Geographic Area

Excluded

2. Excluded Groups. Within the populations identified above as Mandatory or Voluntary,
there may be certain groups of individuals who are excluded from the managed care
program. Please indicate if any of the following groups are excluded from participating in
the program:

☐Other Insurance--Medicaid beneficiaries who have other health insurance.
☐Reside in Nursing Facility or ICF/MR--Medicaid beneficiaries who reside in Nursing
Facilities (NF) or Intermediate Care Facilities for the Mentally Retarded (ICF/MR).
☐Enrolled in Another Managed Care Program--Medicaid beneficiaries who are enrolled
in another Medicaid managed care program
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☐Eligibility Less Than 3 Months--Medicaid beneficiaries who would have less than
three months of Medicaid eligibility remaining upon enrollment into the program.
☐Participate in HCBS Waiver--Medicaid beneficiaries who participate in a Home and
Community Based Waiver (HCBS, also referred to as a 1915(c) waiver).
☐ Retroactive Eligibility–Medicaid beneficiaries for the period of retroactive eligibility.
☐ Other (Please define):
1932(a)(4)

F.

Enrollment Process.
1.

2.

Definitions.
a.

Auto Assignment- assignment of a beneficiary to a health plan when the
beneficiary has not had an opportunity to select their health plan.

b.

Default Assignment- assignment of a beneficiary to a health plan when the
beneficiary has had an opportunity to select their health plan.

Please describe how the state effectuates the enrollment process. Select an
enrollment methodology from the following options and describe the elements listed
beneath it:
a.

☐ The applicant is permitted to select a health plan at the time of application.
i.

How the state fulfills its obligations to provide information as specified in
42 CFR 438.10(e).

ii.

What action the state takes if the applicant does not indicate a plan
selection on the application.

iii.

If action includes making a default assignment, describe the algorithm
used and how it meets all of the requirements of 42 CFR 438.50(f).

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iv.

b.

c.

1932(a)(4)
42 CFR 438.50

3.

The state's process for notifying the beneficiary of the default assignment.
(Example: state generated correspondence.)

☐ The beneficiary has an active choice period following the eligibility
determination.
i.

How the beneficiary is notified of their initial choice period, including its
duration.

ii.

How the state fulfills its obligations to provide information as specified in
42 CFR 438.10(e).

iii.

Describe the algorithm used for default assignment and describe the
algorithm used and how it meets all of the requirements of 42 CFR
438.50(f).

iv.

The state's process for notifying the beneficiary of the default assignment.

☐ The beneficiary is auto-assigned to a health plan immediately upon being
determined eligible.
i.

How the state fulfills its obligations to provide information as specified in
42 CFR 438.10(e).

ii.

The state's process for notifying the beneficiary of the auto-assignment.
(Example: state generated correspondence.)

iii.

Describe the algorithm used for auto-assignment and describe the
algorithm used and how it meets all of the requirements of 42 CFR
438.50(f).

State assurances on the enrollment process.
Place a check mark to affirm the state has met all of the applicable requirements of
choice, enrollment, and re-enrollment.
a.

☐The state assures it has an enrollment system that allows Beneficiaries who
are already enrolled to be given priority to continue that enrollment if the MCO

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or PCCM does not have capacity to accept all who are seeking enrollment under
the program.
b.

☐The state assures that, per the choice requirements in 42 CFR 438.52,
Medicaid Beneficiaries enrolled in either an MCO or PCCM model will have a
choice of at least two entities unless the area is considered rural as defined in 42
CFR 438.52(b)(3).

c.

☐ The state plan program applies the rural exception to choice requirements of
42 CFR 438.52(a) for MCOs and PCCMs in accordance with 42 CFR 438.52(b).
Please list the impacted rural counties:
☐This provision is not applicable to this 1932 State Plan Amendment.

d.

☐ The state applies the automatic reenrollment provision in accordance
with 42 CFR 438.56(g) if the recipient is disenrolled solely because he or she
loses Medicaid eligibility for a period of 2 months or less.
☐This provision is not applicable to this 1932 State Plan Amendment.

1932(a)(4)
42 CFR 438.56

G.

H.
1932(a)(5)(c)

Disenrollment.
1.

The state will☐/will not☐ limit disenrollment for managed care.

2.

The disenrollment limitation will apply for

3.

☐The state assures that beneficiary requests for disenrollment (with
and without cause) will be permitted in accordance with 42 CFR 438.56(c).

4.

Describe the state's process for notifying the Medicaid Beneficiaries of their right to
disenroll without cause during the first 90 days of their enrollment. (Examples: state
generated correspondence, HMO enrollment packets etc.)

5.

Describe any additional circumstances of “cause” for disenrollment (if any).

months (up to 12 months).

Information Requirements for Beneficiaries
☐The state assures that its state plan program is in compliance with 42 CFR

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42 CFR 438.50
42 CFR 438.10

438.10(e) for information requirements specific to MCOs and PCCM programs
operated under section 1932(a)(1)(A)(i) state plan amendments.

1932(a)(5)(D)(b)
1903(m)
1905(t)(3)

I.

List all benefits for which the MCO is responsible.

1932(a)(5)(D)(b)(4)
42 CFR 438.228

J.

☐The state assures that each managed care organization has established an
internal grievance procedure for enrollees.

1932(a)(5)(D)(b)(5)
42 CFR 438.206
42 CFR 438.207

K.

Describe how the state has assured adequate capacity and services.

1932(a)(5)(D)(c)(1)(A)
42 CFR 438.240

L.

☐The state assures that a quality assessment and improvement strategy has
been developed and implemented.

1932(a)(5)(D)(c)(2)(A)
42 CFR 438.350

M.

☐The state assures that an external independent review conducted by a
qualified independent entity will be performed yearly.

1932 (a)(1)(A)(ii)

N.

Selective Contracting Under a 1932 State Plan Option
To respond to items #1 and #2, place a check mark. The third item requires a brief
narrative.
1.

The state will☐/will not☐ intentionally limit the number of entities it contracts
under a 1932 state plan option.

2.

☐The state assures that if it limits the number of contracting entities, this
limitation will not substantially impair beneficiary access to services.

3.

Describe the criteria the state uses to limit the number of entities it contracts
under a 1932 state plan option. (Example: a limited number of providers and/or
enrollees.)

4.

☐The selective contracting provision in not applicable to this state plan.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0933. The time required to complete this information collection is estimated to average 10 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
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estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850
CMS-10120 (exp. 3/31/2014)

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