CMS-10108 Network Adequacy and Access Assurances Tool

DRAFT FOR STATE FEEDBACK ONLY

Instructions

Regulations at 42 C.F.R. § 438.207(a) - (c) require Medicaid managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans
(PAHPs)—collectively referred to as “managed care plans”—to submit documentation to the state demonstrating their capacity to serve the expected enrollment of their service areas in
accordance with the state's standards for access to care, including the state's network adequacy and availability of services standards under 42 C.F.R. § 438.68 and 42 C.F.R. §
438.206. Managed care plans are required to submit this information to the state no less frequently than:
Scenario 1: At the time the plan enters into a contract with the state;
Scenario 2: On an annual basis;
Scenario 3: At any time there has been a significant change (as defined by the state) in the plan's operations that would affect the adequacy of capacity and services, including (1)
changes in the plan's services, benefits, geographic service area, composition of or payments to its provider network, or (2) enrollment of a new population in the plan.
After the state reviews the documentation submitted by a plan, 42 C.F.R. § 438.207(d) requires the state to submit to the Centers for Medicare & Medicaid Services (CMS) an assurance
that the plan complies with the state's network adequacy and availability of services standards under 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include
documentation of an analysis that the state conducted to support its assurance of compliance for the plan.
This document provides instructions and a template for states to use when submitting this information to CMS under any of the three scenarios described above. States should complete
one (1) form with information for applicable managed care plans and their applicable managed care programs. For example, if the state submits this form under scenario 1 above, the
state should submit this form only for the managed care plan that entered into a new contract with the state. The state should not report on any other plans or programs. As another
example, if the state submits this form under scenario 2, the state should submit this form for all managed care plans. If the state's analysis methods and results are contained in
separate documents, please also submit those documents with this form.
Consistent with the Managed Care Program Annual Report (MCPAR) required by 42 C.F.R. § 438.66(e), this report defines a program as having a specified set of benefits, eligibility
criteria, and capitation rates that are articulated in a contract between the state and managed care plans.
MMPs are considered both Medicaid and Medicare managed care plans and are not exempt from 42 CFR 438.207. Therefore, states must submit the tool for integrated plans; however,
to reduce duplication, states can complete network adequacy sections of the tool (II.A.1-II.A.5) for Medicaid-only covered services.
States do not need to submit the tool for Program of All-Inclusive Care for the Elderly (PACE) programs/plans as states are not required to do so under 42 CFR 438.207.
Please submit the completed form through an online portal that will be made available. Questions about this form may be directed to
[email protected].
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Organization
This template includes two sections (Section I and Section II). Section I covers descriptive information about the state and all of the managed care programs operating in the state;
information for this section is contained in one tab. Section II includes detail on program-level access standards, monitoring methods, and plan-level compliance data. For Section II,
states should use one tab for each program the state is reporting on and leave unused tabs blank.
Tab topic:
I. State and program-level information
II. Program-level standards, monitoring methods, and plan-level compliance
end of table
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Tab name:
I_State&Prog_Info
II_Prog_X

Number of tabs available:
1
15

Inputting information

Each tab provides instructions in the “Item Instructions” column. Response types are provided in the "Data Format" columns. Only input values in BEIGE CELLS. Program names and
program summary information (i.e., plan types included in a program, services covered under a program) in Section II autopopulates from Section I to reduce burden on states.
After reporting information on each applicable program in the Section II tabs, leave any unused tabs blank. For example, if the state is reporting on plans in five managed care programs,
it should enter information in tabs "II_Prog_1" through "II_Prog_5", and leave the remaining tabs blank.
End of worksheet

September 9, 2020

I. State and program information
A. State information and reporting scenario

States should use this section of the tab to report their contact information, date of report submission, and reporting scenario.
#
Item
Item Instructions
I.A.1
Contact name
Enter the name of the individual(s) filling out this document
I.A.2
Contact email address
Enter the email address(es) of the individual(s) filling out this document
I.A.3
State or territory
Enter the state or territory represented in this document
I.A.4
Date of report submission
Enter the date on which this document is being submitted to CMS

I.A.5

Reporting scenario

Enter the scenario under which the state is submitting this form to CMS. Under 42 C.F.R. § 438.207(c) (d), the state must submit an assurance of compliance after reviewing documentation submitted by a
plan under the following three scenarios:
- Scenario 1: At the time the plan enters into a contract with the state;
- Scenario 2: On an annual basis;
- Scenario 3: Any time there has been a significant change (as defined by the state) in the plan's
operations that would affect its adequacy of capacity and services, including (1) changes in the plan's
services, benefits, geographic service area, composition of or payments to its provider network, or (2)
enrollment of a new population in the plan.

Data Format
Free text
Free text
Set values (select one)
Date (MM/DD/YYYY)

Input state level data in this column
[State]

Set values (select one)

As described in the instructions tab, states should complete one (1) form with information for
applicable managed care plans and programs. For example, if the state submits this form under
scenario 1 above, the state should submit this form only for the managed care plan (and the applicable
managed care program) that entered into a new contract with the state. The state should not report on
any other plans or programs under this scenario. As another example, if the state submits this form
under scenario 2, the state should submit this form for all managed care plans and managed care
programs.

I.A.6

Reporting scenario - other

If the state is submitting this form to CMS for any reason other than those specified in I.A.5, explain the
reason.

Free text

End of table

B. Program information

States should use this section of the tab to report information on applicable managed care programs under the scenario selected in I.A.5, including
reporting periods and providers covered under the programs.
#
Item
Item Instructions

I.B.1

I.B.2

Input program-level data in beige cells in columns for Program 1 through Program 15>>
Data Format

Program name

Enter the name of each managed care program in the state in columns E - S. After entering each
managed care program name, leave any unused columns in E - S blank. A program is defined by a
specified set of benefits, eligibility criteria, and capitation rates that are articulated in a contract between
the state and managed care plans. If more than one program is included in a single contract, enter one
program per column, starting with column E. Each program entered into these fields will auto-populate
program fields in the remaining tabs of this document

Statutory authority

Enter the statutory authority(ies) (e.g. Section 1115, 1915(b), etc.) for each managed care program in
the state in columns E - S. After entering the authority(ies) for each program, leave any unused columns Free text
in E - S blank.

Indicate the managed care plan type (MCO, PIHP, PAHP, or MMP) that contracts with the state in each
Plan type included in program
program.
Reporting Period
For items I.B.4 and I.B.5, indicate the reporting period for the analysis and compliance information entered into this report. CMS expects states to enter a
reporting period end date that is no more than one year prior to the sub mission of this report.
I.B.3

Under scenario 1 (new contract) and 3 (significant change in plan operations), the reporting period may cover less than one year.

Reporting period start date

I.B.5

Reporting period end date

For each program, enter the start date of the reporting period for the analysis and compliance
information entered into this report
For each program, enter the end date of the reporting period for the analysis and compliance
information entered into this report

Providers
For items I.B.6.a - k, indicate whether the program covers each 42 C.F.R. § 438.68 provider type specified.

Adult primary care
Pediatric primary care
OB/GYN
Adult behavioral health
Pediatric behavioral health
Adult specialist
Pediatric specialist
Hospital
Pharmacy
Pediatric dental
LTSS

I.B.6.l

Other (optional field for the state)

End of table

Indicate whether the program covers adult primary care providers
Indicate whether the program covers pediatric primary care providers
Indicate whether the program covers Ob/Gyn providers
Indicate whether the program covers adult behavioral health providers
Indicate whether the program covers pediatric behavioral health providers
Indicate whether the program covers adult specialist providers
Indicate whether the program covers pediatric specialist providers
Indicate whether the program covers hospital providers
Indicate whether the program covers pharmacy providers
Indicate whether the program covers pediatric dental providers
Indicate whether the program covers long-term services and supports (LTSS) providers
Indicate (1) any notes for items I.B.6.a - k and/or (2) other provider types relevant to the state's network
adequacy standards (42 C.F.R. § 438.68) or availability standards (42 C.F.R. § 438.206) covered under
the program not listed in items I B 6 a - k

[Program 3]

[Program 4]

[Program 5]

[Program 6]

[Program 7]

[Program 8]

[Program 9]

[Program 10]

[Program 11]

[Program 12]

[Program 13]

[Program 14]

[Program 15]

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(none)

Date (MM/DD/YYYY)
Date (MM/DD/YYYY)

(none)

For MMPs, only enter providers of Medicaid-only covered services. Do not enter providers of Medicaid and Medicare or Medicare-only covered services.
I.B.6.a
I.B.6.b
I.B.6.c
I.B.6.d
I.B.6.e
I.B.6.f
I.B.6.g
I.B.6.h
I.B.6.i
I.B.6.j
I.B.6.k

[Program 2]

Set values (select one) or use
free text for "other" response

Under scenario 2 (annual report), the reporting period should cover one year.
I.B.4

[Program 1]

Free text

Set values
Set values
Set values
Set values
Set values
Set values
Set values
Set values
Set values
Set values
Set values

(select one)
(select one)
(select one)
(select one)
(select one)
(select one)
(select one)
(select one)
(select one)
(select one)
(select one)

Free text (optional field for the
state)

C. Separate analysis and results documents

States should use this section of the tab to report on separate documents submitted with this form that contain the state's analysis and results
information requested in tabs "II_Prog_X".
#
Item
Item Instructions

Input program-level data in beige cells in columns for Program 1 through Program 15>>
Data Format

[Program 1]

[Program 2]

[Program 3]

[Program 4]

[Program 5]

[Program 6]

[Program 7]

[Program 8]

[Program 9]

[Program 10]

[Program 11]

[Program 12]

[Program 13]

[Program 14]

[Program 15]

(header/blank cell)

(header/blank cell)

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(header/blank cell)

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For item I.C.1, indicate for each program in columns E-S whether the state's analysis methods and results regarding plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards are contained in a separate document(s). Before indicating “yes”, ensure that the document(s)
contains the information requested in tabs "II_Prog_X".
If the state reports "yes" in I.C.1 , indicate in items I.C.2 - I.C.4 the name and date of the document(s) as well as the page/section numbers for where the (none)
program is addressed in the document(s). Submit the document(s) with this form.
For any program for which the state reports "no" in I.C.1 (meaning that the state does not report analysis methods and results in a separate
document[s]), the state must enter data in Sections B and C in tabs "II_Prog_X".

I.C.1

Analysis and results in separate
documents

For each program in columns E-S, indicate whether the state's analysis methods and results regarding
plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards are contained
Set values (select one)
in a separate document(s). If yes, submit the document(s) with this form.

I.C.2

Name of analysis and results
documents

If the state indicated that analysis methods and results are contained in a separate document(s) for
any program in columns E-S, indicate the name of the document(s). If analysis methods and results
are not contained in a separate document(s), write "N/A."

Free text

I.C.3

Date of analysis and results
documents

If the state indicated that analysis methods and results are contained in a separate document(s) for
any program in columns E-S, indicate the date of the document(s). If analysis methods and results are
not contained in a separate document(s), write "N/A."

Free text

I.C.4

Page/section references in analysis
and results documents

If the state indicated that analysis methods and results are contained in a separate document(s) for
any program in columns E-S, indicate the page/section numbers for where the program is addressed
in the document(s). If analysis methods and results are not contained in a separate document(s), write
"N/A."

Free text

End of worksheet

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 1]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab.

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program, write "N/A."

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 2 a write "N/A "

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 3 a write "N/A "

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 3 a write "N/A "

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 2]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 3]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 4]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab.

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program, write "N/A."

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 2 a write "N/A "

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 3 a write "N/A "

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II C 3 a write "N/A "

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 5]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 6]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 7]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 8]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 9]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 10]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 11]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 12]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 13]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 14]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100

II. Program-level standards, monitoring methods, and plan compliance
Values in the box below auto-populate f rom the "I_State&Prog_Inf o" tab.

Program summary

[Program 15]

Plan type included in program contracts

(Placeholder f or plan ty pe)

Provider types covered in program contracts

(Placeholder f or prov iders)

Analysis and results in separate document

(Placeholder f or separate analy sis and results document)

Name of analysis and results document

(Placeholder f or separate analy sis and results document)

Date of analysis and results document

(Placeholder f or separate analy sis and results document)

WARNING: Assurances not y et reported to II.C.2.a and II.C.3.a

WARNING: Inf o not y et reported to II.B.1-3

Context: Regulations at 42 C.F.R. § 438.207(d) require states that contract with MCOs, PIHPs, and PAHPs to submit to CMS an
assurance of compliance that each plan meets the state's network adequacy and av ailability of serv ices standards under 42
C.F.R. § 438.68 and 42 C.F.R. § 438.206. The submission must include documentation of an analy sis that the state conducted to
support its assurance of compliance f or each plan. The state must submit this inf ormation to CMS af ter receipt of documentation
f rom a managed care plan as specif ied in 42 C.F.R. § 438.207(c) and described in the instructions tab. The f ields below prov ide a
template f or states to submit this inf ormation f or the program listed at the top of the tab

A. Access and network adequacy standards required for plans participating in the
program

States should use this section of the tab to report each standard included in managed care program contracts; report each unique
standard in columns E - CZ.

Input program-lev el data in columns f or Standard 1 through Standard 100>>

#

Item

Item Instructions

Data Format

II.A.1

Standard ty pe

Enter the standard ty pe f or each standard used in the program.

Standard description

Describe the standard (f or example, 60 miles maximum distance to trav el to
an appointment)

Set v alues (select one) or use
f ree text f or "other" response

II.A.2
II.A.3

Prov ider ty pe cov ered by standard

Enter the prov ider ty pe that the standard applies to.

II.A.4

Population cov ered by standard

Enter the population that the standard applies to.

II.A.5

Applicable region(s)

Enter the region that the standard applies to.

End of table

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 6

Standard 7

Standard 8

Secret Shopper:
Appointment
Availability

EVV Data Analysis

Review of Grievances
Related to Access

Encounter Data
Analysis

Other (Specify)

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Standard 17

Standard 18

Standard 19

Standard 20

Standard 21

Standard 22

Standard 23

Standard 24

Standard 25

Standard 26

Standard 27

Standard 28

Standard 29

Standard 30

Standard 31

Standard 32

Standard 33

Standard 34

Standard 35

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response
Set v alues (select one) or use
f ree text f or "other" response

B. Analyses that the state uses to monitor compliance with access and network
adequacy standards reported in Section A

States should use this section of the tab to report on the analy ses that the state uses to assess plan compliance with the state's
42 C.F.R. § 438.68 and 42 C.F.R. § 438.206 standards; report on each analy sis in columns E - L.

Input program-lev el data in these column unless specif ied in the item instructions >>

#

Item

Item Instructions

Data Format

II.B.1

Frequency of analy sis

Indicate how f requently the state analy zes plan compliance with 42 C.F.R. §
438.68 and/or 42 C.F.R. § 438.206 f or the program being reported on in this
tab using the methods listed in columns E-L. If the state does not use the
method, select "Not used f or any plans".

Set v alues (select one) or use
f ree text f or "other" response

II.B.2

Analy sis methods

For each analy sis method in columns E-L, indicate whether the state uses the
method to analy ze plan compliance with 42 C.F.R. § 438.68 and/or 42 C.F.R.
§ 438.206 f or all, some, or none of the plans in the program being reported on
in this tab. If the state uses other methods, please explain them in column L.
If the state enters 'Used f or some but not all plans' f or any method, report
the plans f or which it uses the method in II.B.3.

Set v alues (select one) or use
f ree text f or "other" response

II.B.3

Plan-specif ic analy sis

If the state indicated in item II.B.2 that it uses an analy sis method f or some
but not all plans in the program, identif y the subset of plans f or which the
method is used. Write the name of the plan(s) under the column
corresponding with the ty pe of analy sis. If the state indicated in item II.B.2
that it uses the method on all or none of the plans in the program write "N/A "

Free text

Geomapping

Plan Provider
Directory Review

Secret Shopper:
Network Participation

End of table

C. Plan-level compliance data

States should use this section of the tab to report on plan compliance with the state's 42 C.F.R. § 438.68 and 42 C.F.R. § 438.206
standards; report on each plan in columns E - AR.

Input plan-lev el data in columns f or Plan 1 through Plan 40 >>

#

Item

Item Instructions

Data Format

II.C.1.

Plan name

In columns E - AR, enter the names of the plans that contract with the state
f or the managed care program identif ied abov e

Free text

Indicate whether the state assures that the plan complies with the state's
network adequacy standards under 42 C.F.R. § 438.68 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.2.

Assurance of plan compliance with 42
C.F.R. § 438.68

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.68 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.68 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

Description of results: 42 C.F.R. §
438.68

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.68 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 1)

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe plan def iciencies identif ied during
the reporting period and indicate which analy ses uncov ered the def iciencies.
If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Free text

II.C.2.

Plan def iciencies: 42 C.F.R. § 438.68
(Part 2)

II.C.2.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.68

If the state identif ied any plan def iciencies in II.C.2.c, indicate when the
state will reassess the plan's network to determine whether the plan has
remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

II.C.2.

Exceptions granted under 42 C.F.R. §
438.68(d)

Describe any network adequacy standard exceptions that the state has
granted to the plan under 42 C.F.R. § 438.68(d). If there are no exceptions,
write "None."

Free text

II.C.2.

Justif ication f or exceptions granted under
42 C.F.R. § 438.68(d)

If the state identif ied any network adequacy standard exceptions granted to
the plan under 42 C.F.R. § 438.68(d) in II.C.2.f , describe the state's
justif ication f or granting the exception(s). If the state has not granted any
exceptions, write "N/A."

Free text

II.C.2.

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.68 standards based on at least one analy sis conducted within the
reporting period in I.B.4 and I.B.5, describe what the plan will do to achiev e
compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.2.a, write "N/A."

Indicate whether the state assures that the plan complies with the state's
av ailability of serv ices standards under 42 C.F.R. § 438.206 based on each
analy sis the state conducted f or the plan during the reporting period indicated
in I.B.4 and I.B.5.

II.C.3.

Assurance of compliance with 42 C.F.R.
§ 438.206

For example, if the state assessed plan compliance using f our quarterly
geomapping and two semi-annual plan prov ider roster rev iew analy ses within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan complied with the state's 42 C.F.R. § 438.206 standards in all of
those analy ses, enter 'y es, the plan complies based on all analy ses.'

Set v alues (select one)

As another example, if the state assessed plan compliance using two semiannual geomapping analy ses and an annual secret shopper analy sis within
the reporting period indicated in I.B.4 and I.B.5, and the state determined that
the plan did not comply with the state's 42 C.F.R. § 438.206 standards in at
least one of those analy ses, enter 'no, the plan does not comply based on all
analy ses.'

II.C.3.

Description of results: 42 C.F.R. §
438.206

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 1)

Describe the results of each of the analy ses (including dates of the
analy ses) that support the assurance abov e of the plan's compliance with the
state's 42 C.F.R. § 438.206 standards. In the description of results, please
address the standards that apply to the plan and each of the analy ses that
the state used to assess plan compliance with those standards.
If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe plan def iciencies
identif ied during the reporting period and indicate which analy ses uncov ered
the def iciencies.

Free text

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

II.C.3.

Plan def iciencies: 42 C.F.R. § 438.206
(Part 2)

II.C.3.

Reassessment f or plan def iciencies: 42
C.F.R. § 438.206

If the state cannot assure plan compliance with the state's 42 C.F.R. §
438.206 standards based on at least one analy sis conducted within the
reporting period indicated in I.B.4 and I.B.5, describe what the plan will do to
achiev e compliance and how the state will monitor the plan's progress.

Free text

If the state selected "Y es, the plan complies based on all analy ses" in
II.C.3.a, write "N/A."

End of worksheet

If the state identif ied any plan def iciencies in II.C.3.c, indicate when the
state will reassess the plan's av ailability of serv ices to determine whether the
plan has remediated those def iciencies.

Date (MM/DD/Y Y Y Y )

[Plan 1]

[Plan 2]

[Plan 3]

Standard 36

Standard 37

Standard 38

Standard 39

Standard 40

[Plan 36]

[Plan 37]

[Plan 38]

[Plan 39]

[Plan 40]

Standard 41

Standard 42

Standard 43

Standard 44

Standard 45

Standard 46

Standard 47

Standard 48

Standard 49

Standard 50

Standard 51

Standard 52

Standard 53

Standard 54

Standard 55

Standard 56

Standard 57

Standard 58

Standard 59

Standard 60

Standard 61

Standard 62

Standard 63

Standard 64

Standard 65

Standard 66

Standard 67

Standard 68

Standard 69

Standard 70

Standard 71

Standard 72

Standard 73

Standard 74

Standard 75

Standard 76

Standard 77

Standard 78

Standard 79

Standard 80

Standard 81

Standard 82

Standard 83

Standard 84

Standard 85

Standard 86

Standard 87

Standard 88

Standard 89

Standard 90

Standard 91

Standard 92

Standard 93

Standard 94

Standard 95

Standard 96

Standard 97

Standard 98

Standard 99

Standard 100