Form CMS-10120 1932(a) State Plan Amendment Template

CMS-PM-10120
Date: [TBD]

ATTACHMENT 3.1-F
Page 1

State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
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], primary care case
managers [PCCMs], and/or PCCM entities) 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 a check mark to
affirm that it will be in compliance no later than the applicable compliance date. All
applicable assurances should be checked, even when the compliance date is in the
future. Please see Appendix A of this document for compliance dates for
various sections of 42 CFR 438.

1932(a)(1)(B)(i)
B.
1932(a)(1)(B)(ii)
42 CFR 438.2
42 CFR 438.6

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
☐Capitation
☐The state assures that all applicable requirements of 42 CFR 438.6,
regarding special contract provisions related to payment, will be met.
2. ☐ PCCM (individual practitioners)
a. ☐ Case management fee
b. ☐ Other (please explain below)

3. ☐ PCCM entity
a. ☐ Case management fee
b. ☐ Shared savings, incentive payments, and/or financial rewards (see
42 CFR 438.310(c)(2))
_____________________________________________________________________________________________
TN No.
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Approval Date
Effective Date
TN No.

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CMS-PM-10120
Date: [TBD]

State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
c. ☐ Other (please explain below)
If PCCM entity is selected, please indicate which of the following
function(s) the entity will provide (as in 42 CFR 438.2), in addition to PCCM
services:
☐ Provision of intensive telephonic case management
☐ Provision of face-to-face case management
☐ Operation of a nurse triage advice line
☐ Development of enrollee care plans.
☐ Execution of contracts with fee-for-service (FFS) providers in the
FFS program
☐ Oversight responsibilities for the activities of FFS providers in the
FFS program
☐ Provision of payments to FFS providers on behalf of the State.
☐ Provision of enrollee outreach and education activities.
☐ Operation of a customer service call center.
☐ Review of provider claims, utilization and/or practice patterns to
conduct provider profiling and/or practice improvement.
☐ Implementation of quality improvement activities including
administering enrollee satisfaction surveys or collecting data
necessary for performance measurement of providers.
☐ Coordination with behavioral health systems/providers.
☐ Coordination with long-term services and supports systems/providers.
☐ Other (please describe): ____________________________________
______________________________________________________________________
__________________________________________________________
42 CFR 438.50(b)(4)

C.

Public Process.
Describe the public process including tribal consultation, if applicable, utilized for
both the design of themanaged care program and its initial implementation. In
addition, describe what methods the state will use to ensure ongoing public
involvement once the state plan managed care program has been implemented.
(Example: public meeting, advisory groups.)
If the program will include long term services and supports (LTSS), please indicate
how the views of stakeholders have been, and will continue to be, solicited and
addressed during the design, implementation, and oversight of the program,
including plans for a member advisory committee (42 CFR 438.70 and 438.110)

_____________________________________________________________________________________________
TN No.
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Effective Date
TN No.

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ATTACHMENT 3.1-F
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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
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.

1932(a)(1)(A)(i)(I)
1905(t)

2.

☐ The state assures that all the applicable requirements of section 1905(t)
of the Act for PCCMs and PCCM contracts (including for PCCM entities) 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)
42 CFR 438.10(g)(2)(vii)

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, PCCMs, and PCCM entities will be met.

1932(a)(1)(A)

7.

☐ The state assures that all applicable requirements of 42 CFR 438.4, 438.5,
438.7, 438.8, and 438.74 for payments under any risk contracts will be met.

8.

☐ The state assures that all applicable requirements of 42 CFR 447.362 for

42 CFR 438.50(c)(2)
1902(a)(23)(A)

42 CFR 438.4
42 CFR 438.5
42 CFR 438.7
42 CFR 438.8
42 CFR 438.74
42 CFR 438.50(c)(6)
1932(a)(1)(A)

_____________________________________________________________________________________________
TN No.
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Effective Date
TN No.

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ATTACHMENT 3.1-F
Page 4

State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
42 CFR 447.362
42 CFR 438.50(c)(6)

payments under any non-risk contracts will be met.
☐ The state assures that all applicable requirements of 45 CFR 75.326 for
procurement of contracts will be met.

45 CFR 75.326

9.

42 CFR 438.66

10. Assurances regarding state monitoring requirements:
☐ The state assures that all applicable requirements of 42 CFR 438.66(a), (b),
and (c), regarding a monitoring systemand using data to improve the
performance of its managed care program, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.66(d),
regarding readiness assessment, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.66(e),
regarding reporting to CMS about the managed care program, will be met.

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

E. Populations and Geographic Area
1. Included Populations. Please check which eligibility groups are included, if
they are enrolled on a Mandatory (M) or Voluntary (V) basis (as defined in 42
CFR 438.54(b)) or Excluded (E), and the geographic scope of enrollment.
Under the Geographic Area 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. Also, if type of enrollment
varies by geographic area (for example, mandatory in some areas and voluntary
in other areas), please note specifics in the Geographic Area column.
Under the Notes column, please noteany additional relevant details about the
population or enrollment.

Eligibility Group

Citation
(Regulation [42
CFR] or SSA)

M V

E

Geographic Area

Notes

(include specifics if
M/V/E varies by area)

A. Mandatory Eligibility Groups (Eligibility Groups to which a state must provide Me dicaid cove rage)
•
Family/Adult
1. Parents and Other Caretaker Relatives
§435.110
2. Pregnant Women
§435.116
3. Children Under Age 19 (Inclusive of
§435.118
Deemed Newborns under §435.117)
4. Former Foster Care Youth (up to age 26) §435.150
5. Adult Group (Non-pregnant individuals
§435.119
age 19-64 not eligible for Medicare with
income no more than 133% FPL )

_____________________________________________________________________________________________
TN No.
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Approval Date
Effective Date
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CMS-PM-10120
Date: [TBD]

State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Eligibility Group

Citation
(Regulation [42
CFR] or SSA)

6.

T ransitional Medical Assistance (Includes
adults and children, if not eligible under
§435.116, §435.118, or §435.119)

7.

Extended Medicaid Due to Spousal
Support Collections
•
Age d/Blind/Disabled Individuals
Individuals Receiving SSI age 19 and over
only (See E.2. below regarding age <19)
Aged and Disabled Individuals in 209(b)
States
Individuals Who Would be Eligible for
SSI/SSP but for OASDI COLA Increase
since April, 1977
Disabled Widows and Widowers
Ineligible for SSI due to an increase of
OASDI
Disabled Widows and Widowers
Ineligible for SSI due to Early Receipt of
Social Security
Working Disabled under 1619(b)

8.
9.
10.

11.

12.

13.

14. Disabled Adult Children
B. O ptional Eligibility Groups
1.
2.
3.
4.
5.
6.

7.

• Family/Adult
Optional Parents and Other Caretaker
Relatives
Optional T argeted Low-Income Children
Independent Foster Care Adolescents
Under Age 21
Individuals Under Age 65 with Income
Over 133%
Optional Reasonable Classifications of
Children Under Age 21
Individuals Electing COBRA
Continuation Coverage
•
Age d/Blind/Disabled Individuals
Aged, Blind or Disabled Individuals
Eligible for but Not Receiving Cash

M V

E

Geographic Area

Notes

(include specifics if
M/V/E varies by area)

1902(a)(52),
1902(e)(1), 1925,
and 1931(c)(2) of
SSA
§435.115

§435.120
§435.121
§435.135

§435.137

§435.138

1619(b),
1902(a)(10)(A)(i)(
II), and 1905(q) of
SSA
1634(c) of SSA

§435.220
§435.229
§435.226
§435.218
§435.222
1902(a)(10)(F) of
SSA
§435.210 and
§435.230

_____________________________________________________________________________________________
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ATTACHMENT 3.1-F
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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Eligibility Group

Citation
(Regulation [42
CFR] or SSA)

8.
9.

10.

11.

12.
13.
14.

Individuals eligible for Cash except for
Institutionalized Status
Individuals Receiving Home and
Community-Based Waiver Services Under
Institutional Rules
Optional State Supplement Recipients 1634 and SSI Criteria States – with 1616
Agreements
Optional State Supplemental Recipients­
209(b) States and SSI criteria States
without 1616 Agreements
Institutionalized Individuals Eligible under
a Special Income Level
Individuals Participating in a PACE
Program under Institutional Rules
Individuals Receiving Hospice Care

15. Poverty Level Aged or Disabled

16. Work Incentive Group
17. T icket to Work Basic Group
18. T icket to Work Medically Improved
Group
19. Family Opportunity Act Children with
Disabilities
20. Individuals Eligible for State Plan Home
and Community-Based Services

• Partial Benefits
21. Family Planning Services
22. Individuals with T uberculosis
23. Individuals Needing T reatment for Breast
or Cervical Cancer (under age 65)
C. Me dically Ne edy
1. Medically Needy Pregnant Women
2.

Medically Needy Children under Age 18

M V

E

Geographic Area

Notes

(include specifics if
M/V/E varies by area)

§435.211
§435.217

§435.232

§435.234

§435.236
1934 of the SSA
1902(a)(10)(A)(ii)
(VII) and 1905(o)
of the SSA
1902(a)(10)(A)(ii)
(X) and
1902(m)(1) of the
SSA
1902(a)(10)(A)(ii)
(XIII) of the SSA
1902(a)(10)(A)(ii)
(XV) of the SSA
1902(a)(10)(A)(ii)
(XVI) of the SSA
1902(a)(10)(A)(ii)
(XIX) of the SSA
§435.219

§435.214
§435.215
§435.213

§435.301(b)(1)(i)
and (iv)
§435.301(b)(1)(ii)

_____________________________________________________________________________________________
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ATTACHMENT 3.1-F
Page 7

State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Eligibility Group

Citation

M V

E

(Regulation [42
CFR] or SSA)

3.
4.
5.
6.
7.
8.

Medically Needy Children Age 18 through
20
Medically Needy Parents and Other
Caretaker Relatives
Medically Needy Aged
Medically Needy Blind
Medically Needy Disabled
Medically Needy Aged, Blind and
Disabled in 209(b) States

Geographic Area

Notes

(include specifics if
M/V/E varies by area)

§435.308
§435.310
§435.320
§435.322
§435.324
§435.330

2. Voluntary Only or Excluded Populations. Under this managed care authority, some
populations cannot be subject to mandatory enrollment in an MCO, PCCM, or PCCM
entity (per 42 CFR 438.50(d)). Some such populations are Eligibility Groups separate from
those listed above in E.1., while others (such as American Indians/Alaskan Natives) can be
part of multiple Eligibility Groups identified in E.1. above.
Please indicate if any of the following populations are excluded from the program, or
have only voluntary enrollment (even if they are part of an eligibility group listed abovein
E.1. as having mandatory enrollment):
Population

Citation

V

E

Geographic Area

Notes

(Regulation [42
CFR] or SSA)

Me dicare Savings Program – Qualified Medicare
Beneficiaries, Qualified Disabled Working
Individuals, Specified Low Income Medicare
Beneficiaries, and/or Qualifying Individuals
“Dual Eligibles” not de scribe d unde r Me dicare
Savings Program - Medicaid beneficiaries enrolled
in an eligibility group other than one of the Medicare
Savings Program groups who are also eligible for
Medicare
Ame rican Indian/Alaskan Native —
Medicaid beneficiaries who are American Indians or
Alaskan Natives and members of federally
recognized tribes
Children Re ceiving SSI who are Under Age 19 ­
Children under 19 years of age who are eligible for
SSI under title XVI
Q ualified Disabled Children Under Age 19 ­
Certain children under 19 living at home, who are

1902(a)(10)(E)
, 1905(p),
1905(s) of the
SSA

§438.14

§435.120

§435.225
1902(e)(3) of
the SSA

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ATTACHMENT 3.1-F
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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Population

Citation

V

E

Geographic Area

Notes

(Regulation [42
CFR] or SSA)

disabled and would be eligible if they were living in
a medical institution.
Title IV-E Children - Children receiving foster
care, adoption assistance, or kinship guardianship
assistance under title IV-E *
Non-Title IV-E Adoption Assistance Unde r Age
21 *
Children with Spe cial He alth Care Ne eds ­
Receiving services through a family-centered,
community-based, coordinated care system that
receives grant funds under section 501(a)(1)(D) of
T itle V, and is defined by the State in terms of either
program participation or special health care needs.

§435.145

§435.227

* = Note – Individuals in these two Eligibility Groups who are age 19 and 20 can have mandatory enrollment in managed care, while those under
age 19 cannot have mandatory enrollment. Use the Notes column to indicate if you plan to mandatorily enroll 19 and 20 year olds in these Eligibility
Groups.

3. (Optional) Other Exceptions: The following populations (which can be part of various
Eligibility Groups) can be subject to mandatory enrollment in managed care, but states may elect
to make exceptions for these or other individuals.
Please indicate if any of the following populations are excluded from the program, or have
only voluntary enrollment (even if they are part of an eligibility group listed above in E.1. as
having mandatory enrollment):
Population

Voluntary

Excluded

Notes

O the r Insurance--Medicaid beneficiaries who
have other health insurance
Re side in Nursing Facility or ICF/IID-­
Medicaid beneficiaries who reside in Nursing
Facilities (NF) or Intermediate Care Facilities
for Individuals with Intellectual Disabilities
(ICF/IID).
Enrolle d in Another Managed Care
Program--Medicaid beneficiaries who are
enrolled in another Medicaid managed care
program
Eligibility Le ss Than 3 Months--Medicaid
beneficiaries who would have less than three
months of Medicaid eligibility remaining upon
enrollment into the program

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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Population

Voluntary

Excluded

Notes

Participate in HCBS Waiver--Medicaid
beneficiaries who participate in a Home and
Community Based Waiver (HCBS, also
referred to as a 1915(c) waiver).
Re troactive Eligibility–Medicaid beneficiaries
for the period of retroactive eligibility.
O the r (Ple ase de fine ):

1932(a)(4)

42 CFR 438.54

F.

Enrollment Process.
Based on whether mandatory and/or voluntary enrollment are applicable to your program
(see E. Populations and Geographic Area and definitions in 42 CFR 438.54(b)), please
complete the below:
1.

For voluntary enrollment: (see 42 CFR 438.54(c))
a. Please describe how the state fulfills its obligations to provide information as
specified in 42 CFR 438.10(c)(4), 42 CFR 438.10(e) and 42 CFR 438.54(c)(3).
States with voluntary enrollment must have an enrollment choice period or passive
enrollment. Please indicate which will apply to the managed care program:
b. ☐ If applicable, please check here to indicate that the stateprovides an
enrollment choice period, as described in 42 CFR 438.54(c)(1)(i) and 42 CFR
438.54(c)(2)(i), during which individuals who are subject to voluntary
enrollment may make an active choice to enroll in the managed care program, or
will otherwisecontinue to receive covered services through the fee-for-service
delivery system.
i.
Please indicate the length of the enrollment choice
period: _____________
c. ☐ If applicable, please check here to indicate that the state uses a passive
enrollment process, as described in 42 CFR 438.54(c)(1)(ii) and
438.54(c)(2)(ii), for individuals who are subject to voluntary enrollment.
i.
If so, please describe the algorithm used for passive
enrollment and how the algorithm and the state’s
provision of information meets all of the requirements
of 42 CFR 438.54(c)(4),(5),(6),(7), and (8).
ii.
Please indicate how long the enrollee will have to

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ATTACHMENT 3.1-F
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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
disenroll from the plan and return to the fee-for­
service delivery system: _____________
2.

For mandatory enrollment: (see 42 CFR 438.54(d))
a. Please describe how the state fulfills its obligations to provide information as
specified in 42 CFR 438.10(c)(4), 42 CFR 438.10(e) and 42 CFR 438.54(d)(3).
b. ☐ If applicable, please check here to indicate that the stateprovides an
enrollment choice period, as described in 42 CFR 438.54(d)(2)(i), during
which individuals who are subject to mandatory enrollment may make an active
choice to select a managed care plan, or will otherwise be enrolled in a plan
selected by the State’s default enrollment process.
i.
Please indicate the length of the enrollment choice period:
_____________
c. ☐ If applicable, please check here to indicate that the state uses a default
enrollment process, as described in 42 CFR 438.54(d)(5), for individuals who
are subject to mandatory enrollment.
i.
If so, please describe the algorithmused for default enrollment and
how it meets all of the requirements of 42 CFR 438.54(d)(4), (5), (7),
and (8).
d. ☐ If applicable, please check here to indicate that the state uses a passive
enrollment process, as described in 42 CFR 438.54(d)(2), for individuals who
are subject to mandatory enrollment.
i.
If so, please describe thealgorithm used for passive enrollment and
how it meets all of the requirements of 42 CFR 438.54(d)(4), (6), (7),
and (8).

1932(a)(4)
42 CFR 438.54

3.

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 that, per the choice requirements in 42 CFR 438.52:

42 CFR 438.52
i.
ii.

Medicaid beneficiaries with mandatory enrollment in an MCO will
h av e a choice of at least t wo MCOs unless the area is considered
ru ral as d efin ed in 42 CFR 438.52(b )(3);
Medicaid beneficiaries with mandatory enrollment in a primary care
case management system will have a choice of at least two primary care
case managers employed by or contracted with the State;

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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
iii.

Medicaid beneficiaries with mandatory enrollment in a PCCM entity
may be limited to a single PCCM entity and will have a choice of at
least two PCCMs employed by or contracted with the PCCM entity.

42 CFR 438.52
b. ☐ The state plan program applies the rural exception to choice requirements of
42 CFR 438.52(a) for MCOs 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.
42 CFR 438.56(g)
c. ☐ 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.
d. ☐
The state assures that all applicable requirements of 42 CFR 438.71
regarding developing and implementing a beneficiary support system that
provides support to beneficiaries both prior to and after MCO, PCCM, or
PCCM entity enrollment will be met.

42 CFR 438.71

1932(a)(4)
42 CFR 438.56

G.

H.
1932(a)(5)(c)
42 CFR 438.50

Disenrollment.
1.

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

2.

The disenrollment limitation will apply for ________ (up to 12 months).

3.

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

4.

Describe the state's process for notifying the Medicaid beneficiaries of their right to
disenroll without cause during the 90 days following the date of their initial
enrollment into the MCO, PCCM, or PCCM entity. (Examples: state generated
correspondence, enrollment packets, etc.)

5.

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

Information Requirements for Beneficiaries
☐The state assures that its state plan program is in compliance with 42 CFR
438.10 for information requirements specific to MCOs, PCCMs, and PCCM entity

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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
42 CFR 438.10
1932(a)(5)(D)(b)
1903(m)
1905(t)(3)

programs operated under section 1932(a)(1)(A)(i) state plan amendments.
I.

List all benefits for which the MCO is responsible.
Complete the chart below to indicateevery State Plan-Approved services that will
be delivered by the MCO, and where each of those services is described in the
state’s Medicaid State Plan. For “other practitioner services”, list each provider
type separately. For rehabilitative services, habilitative services, EPSDT services
and 1915(i), (j) and (k) services list each program separately by its own list of
services. Add additional rows as necessary.
In the first column of the chart below, enter the name of each State Plan-Approved
service delivered by the MCO. In the second – fourth column of the chart, enter a
State Plan citation providing the Attachment number, Page number, and Item
number, respectively.

State Plan-Approved Service Delivered by the MCO

Medicaid State Plan Citation
Attachment #

Ex. Physical Therapy

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

J.

3.1-A

Page #
4

Item #
11.a

☐ The state assures that each MCO has established an internal grievance and
appeal system for enrollees.

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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________

1932(a)(5)(D)(b)(5)
42 CFR 438.62
42 CFR 438.68
42 CFR 438.206
42 CFR 438.207
42 CFR 438.208

K. Services, including capacity, network adequacy, coordination, and continuity

☐ The state assures that all applicable requirements of 42 CFR 438.62, regarding
continued service to enrollees, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.68, regarding
network adequacy standards, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.206, regarding
availability of services, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.207, regarding
assurances of adequate capacity and services, will be met.
☐ The state assures that all applicable requirements of 42 CFR 438.208, regarding
coordination and continuity of care, will be met.

1932(c)(1)(A)

L. ☐ The state assures that all applicable requirements of 42 CFR 438.330 and
438.340, regarding a quality assessment and performance improvement programand
State quality strategy, will be met.

42 CFR 438.330
42 CFR 438.340
1932(c)(2)(A)

M. ☐ The state assures that all applicable requirements of 42 CFR 438.350, 438.354,
and 438.364 regarding an annual external independent review conducted by a qualified
independent entity, will be met.

42 CFR 438.350
42 CFR 438.354
42 CFR 438.364
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.
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State:

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Citation
Condition or Requirement
_____________________________________________________________________________________________
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 contractsunder
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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State:
_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Appendix A: Compliance Dates (from Supplementary Information in 81 FR 27497, published 5/6/2016)
States must comply with all provisions in effect as of the issuance of this preprint. Additionally, the following
compliance dates apply:
Compliance Dates
Sections
For rating periods for Medicaid managed care contracts
§§   438.3(h), 438.3(m), 438.3(q) through (u),
beginning before July 1, 2017, States will not be held out of
438.4(b)(7), 438.4(b)(8), 438.5(b) through (f),
compliance with the changes adopted in the following sections
438.6(b)(3), 438.6(c) and (d), 438.7(b),
so long as they comply with the corresponding standard(s)
438.7(c)(1) and (2), 438.8, 438.9, 438.10,
codified in 42 CFR part 438 contained in 42 CFR parts 430 to
438.14, 438.56(d)(2)(iv), 438.66(a) through
481, edition revised as of October 1, 2015. States must comply (d), 438.70, 438.74, 438.110, 438.208,
with these requirements no later than the rating period for
438.210, 438.230, 438.242, 438.330, 438.332,
Medicaid managed care contracts starting on or after July 1, 438.400, 438.402, 438.404, 438.406, 438.408,
2017.
438.410, 438.414, 438.416, 438.420, 438.424,
438.602(a), 438.602(c) through (h), 438.604,
438.606, 438.608(a), and 438.608(c) and (d)
For rating periods for Medicaid managed care contracts
§§   438.4(b)(3), 438.4(b)(4), 438.7(c)(3),
beginning before July 1, 2018, states will not be held out of
438.62, 438.68, 438.71, 438.206, 438.207,
compliance with the changes adopted in the following sections
438.602(b), 438.608(b), and 438.818
so long as they comply with the corresponding standard(s)
codified in 42 CFR part 438 contained in the 42 CFR parts 430
to 481, edition revised as of October 1, 2015. States must
comply with these requirements no later than the rating
period for Medicaid managed care contracts starting on or
after July 1, 2018.
States must be in compliance with the requirements at
§   438.4(b)(9) no later than the rating period for Medicaid
managed care contracts starting on or after July 1, 2019.

§   438.4(b)(9)

States must be in compliance with the requirements at
§   438.66(e) no later than the rating period for Medicaid
managed care contracts starting on or after the date of the
publication of CMS guidance.

§   438.66(e)

States must be in compliance with §   438.334 no later than 3
years from the date of a final notice published in the Federal
Register.

§   438.334

Until July 1, 2018, states will not be held out of compliance
§§   438.340, 438.350, 438.354, 438.356,
with the changes adopted in the following sections so long as
438.358, 438.360, 438.362, and 438.364
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State:

_____________________________________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________________________________
Compliance Dates
they comply with the corresponding standard(s) codified in 42
CFR part 438 contained in the 42 CFR parts 430 to 481, edition
revised as of October 1, 2015.

Sections

States must begin conducting the EQR-related activity described §   438.358(b)(1)(iv)
in §   438.358(b)(1)(iv) (relating to the mandatory EQR-related
activity of validation of network adequacy) no later than one
year from the issuance of the associatedEQR protocol.
States may begin conducting the EQR-related activity described
in §   438.358(c)(6) (relating to the optional EQR-related activity
of plan rating) no earlier than the issuance of the associated
EQR protocol.

§   438.358(c)(6)

PRA Disclosure Statement This template may be used by states to easily modify their state plans if they
choose to implement the provisions of 1932(a)(1)(A). Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law. 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 0938-1148
(CMS-10398 #63). The time required to complete this information collection is estimated to take no more
than 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 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

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