Please complete and upload this document into the Health Plan Management System (HPMS) per the SMAC Quick Reference Guide for completed (i.e., signed) contracts with the state Medicaid agency. The matrix will be used to assist the Centers for Medicare & Medicaid Services (CMS) in conducting the state Medicaid agency contract reviews. The responses to this matrix may include items that may have been part of previously signed contracts that are still effective due to it being a multi-year contract, or items that are part of a new amendment. When designating the page numbers and sections below, please note if the page numbers and sections are in an amendment to the state Medicaid agency contract (SMAC). If an element is not applicable, please indicate that in the column titled Not Applicable.
STATE CONTRACT REQUIREMENTS
Contract Number (e.g., H-XXXX): _______________
PBP(s):______________________________________
Date:______________________________________
State:______________________________________
Contract Provision |
Page Number(s) |
Section Number |
Not Applicable |
The signature of the state and plan representatives indicating that this contract is in effect for the upcoming contract year.
NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: If applicable, please use State aid codes to identify category of duals being enrolled. Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number should be completed by applicable D-SNPs; however, if not applicable, please indicate that in the not applicable column. |
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NOTE: For this element, relevant restrictions include if the PBP has enrollment limitations on geographic areas within its approved service area (e.g., closed enrollment in one of multiple approved counties) or specific enrollment limitations (e.g., plan is open to current enrollees but cannot enroll new enrollees).
Page number and section number should be completed by applicable D-SNPs; however, if not applicable, please indicate that in the not applicable column.
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NOTE: Page number and section number should be completed by applicable D-SNPs; however, if not applicable, please indicate that in the not applicable column. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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NOTE: Page number and section number must be completed by all D-SNPs. |
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If you answered “Yes” to Attestation 4, or if your SNP is seeking HIDE or FIDE designations and meets some or all of the following provisions, please also identify the page number and section number for those provisions if the information is in the SMAC. Otherwise, if it is not applicable please indicate that in the not applicable column. |
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applicable, please indicate that in the not applicable column. |
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applicable, please indicate that in the not applicable column. |
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for complying with the notification requirement. If your organization does not designate another entity to provide notification, indicate that in the not applicable column. (422.107(d))
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applicable, please indicate that in the not applicable column. |
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Applicable, please indicate that in the not applicable column. |
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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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Appendix B: Basic Dual Eligible Special Needs Plans State Medicaid Agency Contract Requirements Matrix [PAPERWORK REDUCTION ACT |
Subject | PRA Pkg: Appendix B: DSNP SMAC Requirements Matrix |
Author | CMS-MMCO |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |