CMS Pub. 100-16, ch. mc86c16b, § 20.2.2

Section 164(c)(2) of MIPPA, and as amended by section 3205(d) of the ACA, requires that all D-SNPs have an executed contract with applicable state Medicaid agencies beginning January 1,

2013. See section 1859(f)(3)(D) of the Act and implementing regulations at 42 CFR 422.107.

The Medicare Advantage Dual Eligible Special Need Plans Application, which is available through

HPMS and on the CMS website, provides further information on how and when D-SNPs must

submit their state Medicaid agency contracts (SMACs) and related information to CMS.

CMS requires each D-SNP to submit a SMAC for review by the first Monday in July every year for

each state in which it seeks to operate for the upcoming contract year. A D-SNP with an evergreen

SMAC is still required to submit its contract to CMS by the first Monday in July.

The SMAC must document each entity’s roles and responsibilities with regard to dually eligible

individuals, and must cover the minimum regulatory requirements below:

1. The MAO’s responsibility to coordinate the delivery of, and if applicable, provide

coverage of Medicaid services. (42 CFR 422.107(c)(1))

The SMAC must document the MAO’s responsibility to coordinate the delivery of Medicaid

benefits for individuals who are eligible for such services and, if applicable, provide

coverage of Medicaid benefits, including long-term services and supports and behavioral

health services, for individuals eligible for such services.

2. The categories of eligibility for dually eligible individuals to be enrolled

under the D-SNP. (42 CFR 422.107(c)(2))

The SMAC must clearly identify the dually eligible populations that are eligible to enroll

in the D-SNP. A D-SNP may only enroll dually eligible individuals as specified in the

SMAC. If a SMAC states that a D-SNP can only enroll certain dually eligible individuals

(e.g., full-benefit dually eligible individuals, those aged 65 and above), the MAO must

limit its D-SNP enrollment accordingly.

3. The Medicaid benefits covered under the D-SNP. (42 CFR 422.107(c)(3))

The SMAC must include information on plan benefit design, benefit administration, and

assignment of responsibility for providing, or arranging for, the covered benefits. The

contract must document the Medicaid benefits covered under a capitated contract, as

applicable, between the state Medicaid agency and the MAO offering the D-SNP, the D-SNP’s parent organization, or another entity that is owned and controlled by the D-SNP’s

parent organization. If the list of services is an attachment to the contract, the D-SNP

must reference the list in the body of the contract.

4. The cost sharing protections covered under the D-SNP. (42 CFR 422.107(c)(4))

The SMAC must require that D-SNPs not impose cost sharing on specified dually eligible

individuals (i.e., full-benefit dually eligible individuals, QMBs, or any other population

designated by the state) that exceeds the amount that would be permitted under the state

Medicaid plan if the individual were not enrolled in the D-SNP. In addition, the D-SNP

must meet all MA maximum out-of-pocket (MOOP) requirements, as described in section

20.2.4.1 of this chapter.

5. The identification and sharing of information on Medicaid provider participation. (42

CFR 422.107(c)(5))

The SMAC must enumerate a process for how the state will identify and share

information about providers contracted with the state Medicaid agency so that they may

be included in the D-SNP’s provider directory. Although CMS does not require all

providers to accept both Medicare and Medicaid, the D-SNP’s network must meet the

needs of the dually eligible population served.

6. The verification process of an enrollee’s eligibility for Medicaid. (42 CFR 422.107(c)(6))

The SMAC must require that MAOs receive access to information verifying

eligibility of dually eligible enrollees from the state Medicaid agency. The SMAC

must describe how the D-SNP and the state exchange information to verify each

enrollee’s Medicaid eligibility.

7. The service area covered under the SNP. (42 CFR 422.107(c)(7))

The SMAC must identify the service areas for which the state has agreed the MAO may offer

(i.e., market and enroll beneficiaries in) one or more D-SNPs. The D-SNP service area(s)

must be consistent with the SMAC-approved service area(s).

8. The contract period. (42 CFR 422.107(c)(8))

The SMAC must require a period of performance between the state Medicaid agency and

the D-SNP of at least January 1 through December 31 of the year following the due date

of the contract. Contracts also may be drafted as multi-year, or “evergreen” contracts (i.e.,

continuously valid until a change is made in the contract), as long as the entire calendar

year is covered.

9. Unified appeals and grievances. (42 CFR 422.107(c)(9))

For D-SNPs that meet the definition of an applicable integrated plan as defined in 42 CFR

422.561, the SMAC must require documentation of the use of unified appeals and

grievance procedures under 42 CFR 422.629 through 422.634, 438.210, 438.400, and

438.402.

10. Minimum integration requirement. (42 CFR 422.107(d))

10a. Hospital and skilled nursing facility data notification requirements. (42 CFR

422.107(d)(1))

The SMAC requires any D-SNP that is not a fully integrated or highly integrated D-SNP

(as defined in 422.2), except as specified at 42 CFR 422.107(d)(2) (which is described in

section 10b below), to notify, or arrange for another entity or entities to notify, the state

Medicaid agency, individuals or entities designated by the state Medicaid agency, or both,

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. The SMAC must

establish the timeframe(s) and method(s) by which notice is provided. In the event that a

D-SNP authorizes another entity or entities to perform this notification, the D-SNP must

retain responsibility for complying with the requirement in 42 CFR 422.107(d)(1).

10b. Exception to hospital and SNF data notification requirements for certain D-SNPs

(42 CFR 422.107(d)(2))

The SMAC requirement at 42 CFR 422.107(d)(1) (which is described in section 10a) does

not apply to a D-SNP that meets two conditions:

(1) Under the terms of its SMAC, the D-SNP only enrolls beneficiaries who are not

entitled to full medical assistance under a state plan under title XIX of the Act (i.e.,

partial-benefit dually eligible individuals); and

(2) The D-SNP operates under the same parent organization and in the same service area

as a D-SNP limited to beneficiaries with full medical assistance under a state plan

under title XIX of the Act (i.e., full-benefit dually eligible individuals) that meets the

requirements under 42 CFR 422.107(d)(1).

20.2.2.1 Establishing Integration Status

(Rev.131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)

The process outlined in section 20.2.2.1 relies on CMS regulation at 42 CFR 422.2, which was

codified in the CY 2020 and 2021 MA and Part D Final Rule (CMS-4185-F), which was published on

April 16, 2019.

CMS determines a D-SNP’s status as CO, HIDE, FIDE, and/or AIP based on language in the SMAC.

The matrices that D-SNPs complete inform (but do not dictate) the outcome of the CMS assessment.

We notify MA organizations during the SMAC review of our determination of integration status for

each D-SNP. MA organizations can request a review of that determination during the annual SMAC

review process.

20.2.2.2 Changes in State Medicaid Agency Contracts

(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)

We recognize that states and MA organizations offering D-SNPs may amend the SMAC throughout

the contract year. CMS seeks to maintain the most current version of the executed SMAC within

HPMS as the system of record for MA organizations. While not all changes made in the SMAC

impact provisions set forth in 42 CFR 422.2 and 422.107 specifically, we request the MA

organization submit all amendments made to the SMAC through HPMS.

20.2.2.2.1 Changes in Integration Status

(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)

There are limited circumstances when revisions to the SMAC may affect the integration level of the

D-SNP. These limited circumstances are typically a result of a Medicaid managed care program

procurement or other state contracting process. In many instances the outcome of these procurements

may be protested by losing organizations or disputed through the judicial system. In other instances,

a state Medicaid program may start a new contract period in a month other than January. When

there are changes to the state contracting with the Medicaid managed care plan that impacts the D-SNP’s integration status, the MA organization should submit the revised SMAC to CMS for CMS to

make a redetermination of the integration status. Examples of when CMS expects to review a revised

SMAC and may make a redetermination of the integration level include when:

• The Medicaid managed care contract with the D-SNP, the D-SNP’s parent organization, or

another entity that is owned and controlled by the parent organization adds LTSS and/or

behavioral health covered services that may change the D-SNP from coordination-only to

FIDE or HIDE

• The Medicaid managed care plan affiliated with the D-SNP, the D-SNP’s parent organization

or another entity that is owned and controlled by the parent organization loses its Medicaid

managed care contract with the state mid-year, thus changing the D-SNP from FIDE or

HIDE to coordination-only

• The state makes changes that create enrollment limitations

MA organizations can submit a SMAC revision request directly through the D-SNP Management

Module in HPMS. CMS requests the SMAC revision requests be submitted no later than 30 days prior

to the proposed integration status change. This should allow CMS sufficient time to review the

updated SMAC prior to implementation of the Medicaid managed care program change. We note,

however, that in no instances will an off-cycle redetermination of D-SNP integration status allow for

a mid-year crosswalk of enrollees between D-SNP benefit packages.