CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)

Appendix B - D-SNP State Medicaid Agency Contract Matrix

OMB: 0938-1410

Document [docx]
Download: docx | pdf

Appendix B CMS-10796, OMB 0938-141

D-SNP State Medicaid Agency Contract Matrix


Please complete and upload this document into HPMS per the applicable HPMS user guide instructions located in the HPMS D-SNP Management Module > Documentation 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

Page Number(s)

Section Number

Not Applicable

  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.




  1. 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 D-SNPs.




Contract Provision

Page Number(s)

Section Number

Not Applicable

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


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.




  1. Cost-sharing protections covered under the SNP. (422.107(c)(4))


NOTE: Page number and section number must be completed by all D-SNPs.




  1. 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.




  1. Verification of enrollee’s eligibility for Medicaid. (422.107(c)(6))


NOTE: Page number and section number must be completed by all D-SNPs.




  1. Service area covered by the SNP. (422.107(c)(7))


NOTE: Page number and section number must be completed by all D-SNPs.




  1. 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, 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.

  1. Criteria for identification of the group of high-risk full-benefit 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.

  • 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.




  1. 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.

  • 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.




  1. 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.

  • 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.




  1. 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.

  • 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.




  1. 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.

  • 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.




  1. 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 e-mail, etc.).


NOTE:

  • Page number and section number must be completed for organizations that answered “Yes” to Attestation 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.




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.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPamela Gulliver
File Modified0000-00-00
File Created2022-08-08

© 2024 OMB.report | Privacy Policy