CMS-10796 Appendix C - Special Needs Plan (SNP) Contract Status Re

Appendix C CMS-10796, OMB 0938-1410

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 highly integrated dual eligible (HIDE) SNP and fully integrated dual eligible (FIDE) SNP determination reviews along with determinations for Applicable Integrated Plans. 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, 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 unless the State Medicaid Agency is seeking for the SNP to become applicable integrated plan per 42 CFR 422.561.

NOTE: For organizations that are seeking to become Coordination-Only D-SNPs that meet the definition for Applicable Integrated Plans at 42 CFR 422.561, in addition to uploading the State Medicaid Agency Contract and the corresponding matrices, please upload documentation showing the contractual relationship (if applicable) between your organization’s Medicaid product and the State, or the Medicaid managed care organization that holds the contract with the State, and documentation identifying the covered services.

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	Page Number(s)	Section Number	Not Applicable
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 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. Otherwise if not applicable please indicate that in the not applicable column.
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. Otherwise if not applicable please indicate that in the not applicable column.
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 Medicaid managed care contract can be the MA organization, the parent organization, or other organization owned and controlled by your parent organization.
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.
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-for-service).
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) 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.
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.
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.
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 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.
Language that indicates that your organization or the organization that your entity has a contractual relationship with to provide Medicaid benefits and that has a capitated contract with the State Medicaid Agency provides coverage, consistent with State policy, of: home health services as defined in 42 CFR 440.70 (422.561). NOTE: Page number and section number must be completed for 5, 6, or 7 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation.
Language that indicates that your organization has a capitated contract with the State Medicaid Agency that provides coverage, consistent with State policy, of medical supplies, equipment, and appliances as described in 42 CFR 440.70(b)(3). NOTE: Page number and section number must be completed for 5, 6, or 7 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation.
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. NOTE: Page number and section number must be completed for 5, 6, or 7 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation.

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