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

Appendix A CMS-10796, OMB 0938-1410

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

Attestation	Response
1. Organization has (an) executed contract(s) with the state Medicaid agency in the state(s) in which the applicant seeks to operate for the forthcoming MA application year. Note: Organizations applying for D-SNPs (initial, existing, and existing/expanding) must have a signed state Medicaid agency(ies) Contract(s) by the SMAC submission deadline.	Yes/No
2. Organization’s contract with the state Medicaid agency(ies) qualifies as a highly integrated dual eligible SNP (HIDE SNP). Note: Please refer to the Basic D-SNP State Medicaid Agency Contract Requirements Matrix and the HIDE, FIDE, AIP Contract Requirements Matrix to help make this determination. If the organization attests “Yes,” upload the completed Basic D- SNP State Medicaid Agency Contract Requirements Matrix and HIDE, FIDE, AIP Contract Requirements Matrix with your SMAC by the SMAC submission deadline. NOTE: This attestation and upload should be completed in the HPMS D-SNP Management module at the time of the SMAC submission.	Yes/No
3. Organization’s contract with the State Medicaid Agency(ies) qualifies as a fully integrated dual eligible SNP (FIDE SNP). Note: Please refer to the Basic D-SNP State Medicaid Agency Contract Requirements Matrix and the HIDE, FIDE, AIP Contract Requirements Matrix to help make this determination. If the organization attests "Yes," upload the completed Basic D- SNP State Medicaid Agency Contract Matrix and HIDE, FIDE, AIP Contract Requirements Matrix with your SMAC by the SMAC submission deadline. NOTE: This attestation and upload should be completed in the HPMS D-SNP Management module at the time of the SMAC submission.	Yes/No
4. MA organization has a contract with the state Medicaid agency(ies) that stipulates that the SNP notifies, or arranges for another entity or entities to notify, the state Medicaid agency and/or its designee(s) of hospital and skilled nursing facility admissions for at least one group of high-risk full- benefit dual eligible individuals identified by the state Medicaid agency. If the organization attests “Yes,” upload the completed Basic D-SNP State Medicaid Agency Contract Matrix by the SMAC submission deadline. NOTE: If the organization attested “No” to attestations 2 and 3 in this table, it must attest “Yes” to this attestation.	Yes/No
5. Consistent with the definition of a D-SNP with exclusively aligned enrollment at 422.2, Applicant is a D-SNP that exclusively enrolls full-benefit dual eligible individuals whose Medicaid benefits are covered under a Medicaid managed care organization contract under section 1903(m) of the Act between the applicable state and the D-SNP’s MA organization, the D-SNP’s parent organization, or another entity that is owned and controlled by the D-SNP’s parent organization. NOTE: If the applicant attests “Yes,” then the applicant agrees to use the unified appeals and grievance procedures under §§ 422.629 through 422.634, 438.210, 438.400 and 438.402 and must complete the HIDE, FIDE, AIP Contract Requirements Matrix elements 1 and 2.	Yes/No
6. For organizations seeking HIDE, FIDE, or AIP status, upload the effectuated Medicaid managed care contract with the affiliated the Medicaid managed care organization and the state, including the service area covered by the Medicaid managed care contract.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-1422. This information collection is for a state Medicaid agency contract; a dual eligible special needs plan must have an approved state Medicaid agency contract in place prior to the beginning of the contract year to operate in any given year. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. This information collection is required for MA organizations seeking to offer a dual eligible special needs plan, per 42 CFR 422.107. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.