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

Basic D-SNP State Medicaid Agency Contract Requirements Matrix

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.
Language identifying the legal entity that holds the contract (SMAC) with the state. NOTE: Page number and section number must be completed by all D-SNPs.
How the SNP coordinates the delivery of Medicaid benefits for individuals who are eligible for such services. This includes Medicaid services covered under Medicaid fee-for-service, by the SNP’s MA organization, the SNP itself (or a Medicaid plan offered by the SNP’s parent organization or another entity owned and controlled by its parent organization), or by other Medicaid plans available in the state. (422.107(c)(1)(i)) NOTE: Page number and section number must be completed by all D-SNPs.
The category(ies) and criteria for eligibility for dual eligible individuals to be enrolled under the SNP, including as described in sections 1902(a), 1902(f), 1902(p), and 1905 of the Act. (422.107(c)(2)) NOTE: If applicable, please use State aid codes to identify category of duals being enrolled. Page number and section number must be completed by all D-SNPs.
Language regarding age restriction on enrollment, as applicable. For example, if enrollment in a PBP is limited to individuals who are over age 21, under age 65, or over age 65. 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.
Language regarding geographic or other enrollment restriction, as applicable. 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.
Language that indicates that your organization has a capitated contract with the state Medicaid agency that includes Medicaid payment of Medicare cost sharing. NOTE: Page number and section number should be completed by applicable D-SNPs; however, if not applicable, please indicate that in the not applicable column.
Cost-sharing protections covered under the SNP. (422.107(c)(4)) NOTE: Page number and section number must be completed by all D-SNPs.
Identification and sharing of information on Medicaid provider participation. (422.107(c)(5)) NOTE: Page number and section number must be completed by all D-SNPs.
Verification of enrollee’s eligibility for Medicaid. (422.107(c)(6)) NOTE: Page number and section number must be completed by all D-SNPs.
Service area covered by the SNP. (422.107(c)(7)) NOTE: Page number and section number must be completed by all D-SNPs.
The contract period for the SNP. (422.107(c)(8)) NOTE: Page number and section number must be completed by all D-SNPs.
If you answered “Yes” to Attestation 4, or if your SNP is seeking HIDE or FIDE designations and meets some or all of the following provisions, please also identify the page number and section number for those provisions if the information is in the SMAC. Otherwise, if it is not applicable please indicate that in the not applicable column.
Criteria for identification of the group of high-risk full-benefit dual eligible individuals identified by the State Medicaid Agency for which notification of hospital and skilled nursing facility admissions will apply. (422.107(d)) NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. Otherwise if it is not applicable, please indicate that in the not applicable column.
Language that indicates the entity (your organization or the type of entity or entities) responsible for providing the notification of hospital or skilled nursing facility admissions. (422.107(d)) NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. Otherwise if it is not applicable, please indicate that in the not applicable column.
Language that indicates the entity or entities (the state Medicaid agency, or the state’s designee(s)) responsible for receiving notifications of hospital and skilled nursing facility admissions. (422.107(d)) NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. If it is not applicable, please indicate that in the not applicable column.
If your organization designates another entity(ies) to provide the notification on your behalf, language that indicates that your organization retains responsibility for complying with the notification requirement. If your organization does not designate another entity to provide notification, indicate that in the not applicable column. (422.107(d)) NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. If it is not applicable, please indicate that in the not applicable column.
The timeframe that your organization or your designee has to provide notification of hospital and skilled nursing facility admissions to the state Medicaid agency or its designee(s). (422.107(d)) NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. If it is not applicable, please indicate that in the not applicable column.
The method(s) your organization or your designee uses to provide notification of hospital and skilled nursing facility admissions to the state Medicaid agency or its designee(s). (422.107(d)). (Examples include Health Information Exchange, secure file transfer, secure e-mail, etc.). NOTE: Page number and section number must be completed for organizations that answered “Yes” to Attestation 4. Organizations seeking HIDE or FIDE SNP designation should complete the page number and section number if language is included in SMAC. If it is not Applicable, please indicate that in the not applicable column.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this collection is 0938-1422. 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.