Form CMS-10796 D-SNP State Medicaid Agency Contract Matrix

Appendix A: D-SNP State Medicaid Agency Contract Matrix
Please complete and upload this document into HPMS per HPMS MA Application User Guide
Instructions for completed (i.e., signed) contracts with the State Medicaid Agency. This applies to
items that may have been part of previously signed contracts that are still effective due to it being a
multi-year contract, in addition to any items below that are part of a new amendment. When
designating the page numbers and sections below, please note if the page numbers and sections are in
an amendment to the SMAC. If an element is not applicable, please indicate that in the not applicable
column.
STATE CONTRACT REQUIREMENTS

Plan Name:_________________________________
PBP:______________________________________
Date:______________________________________
State:______________________________________

Contract Provision
1. How the SNP coordinates the delivery of Medicaid benefits for
individuals who are eligible for such services. This includes
Medicaid services covered under Medicaid fee-for-service, by
the SNP’s MA organization, the SNP itself (or a Medicaid plan
offered by the SNP’s parent organization or another entity
owned and controlled by its parent organization), or by other
Medicaid plans available in the state. (422.107(c)(1)(i))
NOTE: Page number and section number must be
completed by all D-SNPs.

2. The category(ies) and criteria for eligibility for dual eligible
individuals to be enrolled under the SNP, including as described
in sections 1902(a), 1902(f), 1902(p), and 1905 of the Act.
(422.107(c)(2)) NOTE: If applicable, please use State aid
codes to identify category of duals being enrolled. Page
number and section number must be completed by all DSNPs.

Page
Number(s)

Section
Number

Not
Applicable

Contract Provision
3. Language that indicates that your organization has a
capitated contract with the State Medicaid Agency that
includes Medicaid payment of Medicare cost sharing.

Page
Number(s)

Section
Number

Not
Applicable

NOTE: Page number and section number should
be completed by applicable D-SNPs; however, if
not applicable please indicate that in the not
applicable column.
4. Cost-sharing protections covered under the SNP.
(422.107(c)(4))
NOTE: Page number and section number must be
completed by all D-SNPs.
5. Identification and sharing of information on Medicaid
provider participation. (422.107(c)(5))
NOTE: Page number and section number must be
completed by all D-SNPs.
6. Verification of enrollee’s eligibility for both Medicare and
Medicaid. (422.107(c)(6))
NOTE: Page number and section number must be
completed by all D-SNPs.
7. Service area covered by the SNP. (422.107(c)(7))
NOTE: Page number and section number must be
completed by all D-SNPs.
8. The contract period for the SNP. (422.107(c)(8))
NOTE: Page number and section number must be
completed by all D-SNPs.
If you answered “Yes” to attestation 4 in section 5.4, or if your SNP is seeking HIDE or FIDE
designations and meets some or all of the following provisions, please also identify the page number
and section number for those provisions if the information is in the SMAC. Otherwise, if it is not
applicable please indicate that in the not applicable column.
9. Criteria for identification of the group of high-risk fullbenefit dual eligible individuals identified by the State
Medicaid Agency for which notification of hospital and
skilled nursing facility admissions will apply. (422.107(d))
NOTE:

Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
10. Language that indicates the entity (your organization or the
type of entity or entities) responsible for providing the
notification of hospital or skilled nursing facility
admissions. (422.107(d))
•

NOTE:
• Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
11. Language that indicates the entity or entities (the State
Medicaid Agency, or the State’s designee(s)) responsible
for receiving notifications of hospital and skilled nursing
facility admissions. (422.107(d))
NOTE:
• Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
12. If your organization designates another entity(ies) to
provide the notification on your behalf, language that
indicates that your organization retains responsibility
for complying with the notification requirement.
(422.107(d))
NOTE:

Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
13. The timeframe that your organization or your designee has
to provide notification of hospital and skilled nursing
facility admissions to the State Medicaid Agency or its
designee(s). (422.107(d))
•

NOTE:
• Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
14. The method(s) your organization or your designee uses
to provide notification of hospital and skilled nursing
facility admissions to the State Medicaid Agency or its
designee(s). (422.107(d)). (Examples include Health
Information Exchange, secure file transfer, secure email, etc.).
NOTE:
• Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
• Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.