CMS-10796 Special Needs Plan (SNP) Contract Status Review Matrix

Appendix B: Special Needs Plan (SNP) Contract Status Review Matrix
Plans should use this document to identify where each SNP element is met within their
contract(s). The matrix will be used to assist the Centers for Medicare & Medicaid Services
(CMS) in conducting the HIDE and FIDE SNP determination reviews. If an element is not
applicable, please indicate that in the not applicable column.
NOTE: To be designated as a HIDE SNP, a D-SNP must identify contract language for
provision 3 and provisions 5 or 6. To be designated as a FIDE SNP, a D-SNP must provide
contract language for provisions 3-9. Please answer all questions. If an element is not
applicable please indicate that in the not applicable column.
If the applicant is seeking HIDE or FIDE designation, then the following matrix must be
completed.
It is optional for organizations that answered “Yes” to attestation 4 in section 5.4, stipulating
that the SNP notifies, or arranges for another entity or entities to notify, the State Medicaid
Agency and/or its designee(s) of hospital and skilled nursing facility admissions for at least one
group of high-risk full-benefit dual eligible individuals identified by the State Medicaid
Agency, to complete this table.
SPECIAL NEEDS PLAN (SNP) CONTRACT STATUS REVIEW MATRIX
Plan Name: _________________________
Provide the name of the organization that holds the Medicaid managed contract (or PIHP or
PAHP contract) with the State Medicaid Agency:_______________________________________

_________________________
PBP:
Date:
State:
Coverage: LTC____

BH____ Both____

Contract Provision
1. If applicable based on state policy, language that
indicates your organization has exclusively
aligned enrollment, meaning that it only enrolls
full-benefit dual eligible individuals whose
Medicaid benefits are covered under a Medicaid
managed care organization contract under section
1903(m) of the Social Security Act between the

Page
Number(s)

Section
Number

Not
Applicable

Contract Provision
applicable State and your organization, parent
organization or another entity that is owned and
controlled by your organization’s parent
organization. (422.2)
NOTE: All D-SNPs completing this table
must complete this row. The page number
and section number must be completed for
organizations that answered “Yes” to
attestation 5 in section 5.4.
Otherwise if not applicable please indicate
that in the not applicable column.
2. If applicable based on exclusively aligned
enrollment attestation above, language that
describes how your organization uses the
unified appeals and grievance procedures
under 422.629 through 422.634, 438.210,
438.400 and 438.402. (422.107(c)(9))
NOTE: All D-SNPs completing this table
must complete this row. The page number
and section number must be completed for
organizations that answered “Yes” to
attestation 5 in section 5.4.
Otherwise if not applicable please indicate
that in the not applicable column.
3. Language that identifies the entity (your MA
organization, parent organization or other
organization owned and controlled by your parent
organization) that holds the capitated contract
with the State Medicaid Agency. (422.2)
NOTE: Page number and section number
must be completed for organizations seeking
HIDE or FIDE SNP designations.
• For FIDE SNP status only, the same
legal entity must hold both the MA
contract with CMS and the Medicaid
managed care organization (as
defined in 438.2) contract with the
applicable state.
• For HIDE SNP status, the legal entity
that holds the MA contract with CMS
and the legal entity that holds the

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Contract Provision
Medicaid managed care contract can be
the MA organization, the parent
organization, or other organization
owned and controlled by your parent
organization.

4. Language that indicates that your organization
has a capitated contract with the State Medicaid
Agency that provides coverage, consistent with
State policy, of primary and acute care. (422.2)
NOTE:
• Page number and section number must
only be completed for organizations
seeking a FIDE SNP designation.
• Other organizations should complete
the page number and section number if
language is included in the SMAC.
Otherwise if it is not applicable please
indicate this in the not applicable
column.
5. Language that indicates that your
organization has a capitated contract with
the State Medicaid Agency that provides
coverage, consistent with State policy, of
behavioral health services. (422.2)
NOTE: Page number and section number
must be completed for organizations seeking
HIDE or FIDE SNP designations.
• For HIDE SNPs, element 5 OR
element 6 must be completed.
• For FIDE SNP status, coverage of
behavioral health services is not
required when it is not consistent
with state policy (i.e., Medicaid
behavioral health is covered by the
State through Medicaid Fee-forservice).
6. Language that indicates that your organization
has a capitated contract with the State Medicaid
Agency that provides coverage, consistent with
State policy, of long- term services and
supports, including in community-based
settings. (422.2)

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Number(s)

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Number

Not
Applicable

Contract Provision
NOTE: Page number and section number
must be completed for organizations seeking
HIDE or FIDE SNP designations.
• For HIDE SNP status, element 5 OR
element 6 must be completed.
7. Language that indicates that your organization
has a capitated contract with the State Medicaid
Agency that provides coverage, consistent with
State policy, of nursing facility services for a
period of at least 180 days during the plan year.
(422.2)
NOTE:
• Page number and section number
must only be completed for FIDE
SNP designation.
• Other organizations should
complete the page number and
section number if language is
included in the SMAC. Otherwise
if it is not applicable please indicate
that in the not applicable column.
8. Language that describes how your organization
coordinates the delivery of covered Medicare
and Medicaid services using aligned care
management and specialty care network
methods for high-risk beneficiaries. (422.2)
NOTE:
• Page number and section number
must only be completed for FIDE
SNP designation.
• Other organizations should
complete the page number and
section number if language is
included in the SMAC. Otherwise if
it is not applicable please indicate
that in the not applicable column.
9. Language that indicates that your organization
employs policies and procedures approved by
CMS and the State to coordinate or integrate
beneficiary communication materials,
enrollment, communications, grievance and

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Contract Provision
appeals, and quality improvement. (422.2)
NOTE:
• Page number and section number
must only be completed for FIDE
SNP designation.
• Other organizations should
complete the page number and
section number if language is
included in the SMAC. Otherwise if it
is not applicable please indicate that in
the not applicable column.

Page
Number(s)

Section
Number

Not
Applicable