CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestatio

Appendix A CMS-10796, OMB 0938-1410

D-SNP State Medicaid Agency(ies) Contract(s): Attestations

CMS will send HPMS memo indicating when the D-SNP Management Module will be available to complete the attestations and submit the necessary uploads. The SMAC documents will be due by the first Monday in July.

Attestation	Response
1. Organization has an existing, executed contract(s) with the State Medicaid Agency in the state(s) in which the applicant seeks to operate for the MA application year by July 3, 2023. Note: Organizations applying for dual-eligible SNPs (initial, existing, and existing/expanding) must have a signed State Medicaid Agency(ies) Contract(s) by the CMS specified deadline. A current (evergreen) contract with a letter of good standing, a current (evergreen) contract with amendments, or future contract, must be uploaded each application cycle or year.	Yes/No
2. Organization’s contract with the State Medicaid Agency(ies) qualifies as a highly integrated dual eligible SNP (HIDE SNP). Note: Please refer to the D-SNP State Medicaid Agency Contract Matrix and the SNP Status Contract Matrix to help make this determination. If the organization attests “Yes,” upload the completed D- SNP State Medicaid Agency Contract Matrix and SNP Status Contract Matrix with your SMAC before July 3, 2023.	Yes/No
3. Organization’s contract with the State Medicaid Agency(ies) qualifies as a fully integrated dual eligible SNP (FIDE SNP). Note: Please refer to the D-SNP State Medicaid Agency Contract Matrix and the SNP Status Contract Matrix to help make this determination. If the organization attests "Yes," upload the completed D- SNP State Medicaid Agency Contract Matrix and SNP Status Contract Matrix with your State Medicaid Agency Contract before July 3, 2023.	Yes/No
4. MA Organization has a contract with the State Medicaid Agency(ies) that stipulates 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. If the organization attests “Yes,” upload the completed D-SNP State Medicaid Agency Contract Matrix before July 3, 2023 NOTE: If Organization attested “No” to attestations 2 and 3 in this table, it must attest “Yes” to this attestation.	Yes/No
5. Consistent with the definition of a SNP with exclusively aligned enrollment at 422.2, Applicant is a SNP that exclusively enrolls full-benefit dual eligible individuals whose Medicaid benefits are covered under a Medicaid managed care organization contract under section 1903(m) of the Act between the applicable State and the SNP’s MA organization, the SNP’s parent organization, or another entity that is owned and controlled by the D-SNP’s parent organization. NOTE: If the applicant attests “Yes,” and is a FIDE SNP or HIDE SNP, per the responses to attestations 2 and 3 of this section, or if the applicant attests “Yes,” and is a Coordination-only SNP, per the response to attestation 4 and meets the requirements set forth in 42 CFR 422.561, then the applicant agrees to use the unified appeals and grievance procedures under 422.629 through 422.634, 438.210, 438.400 and 438.402 and must complete the SNP Status Contract Matrix elements 1 and 2.	Yes/No

PRA Disclosure Statement 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 collection is 0938-1422 (Expires XX/XX/202X).  The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection.  If you have any 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, Baltimore, Maryland 21244-1850.