Appendix C CMS-10796, OMB 0938-1410
Plans should use this document to identify where each SNP element is met within their contract(s). The matrix will be used to assist the Centers for Medicare & Medicaid Services (CMS) in conducting the highly integrated dual eligible (HIDE) and fully integrated dual eligible (FIDE) SNP determination reviews, as well as determinations for Applicable Integrated Plans (AIPs). If an element is not applicable, please indicate that in the not applicable column.
If the applicant is seeking HIDE or FIDE integration status and/or AIP designation, then the following matrix must be completed.
NOTE: To be designated as a HIDE SNP, a D-SNP must identify contract language for provision 3 and provisions 5 or 6. To be designated as a FIDE SNP, a D-SNP must identify contract language for provisions 3-9. Please answer all questions. If an element is not applicable, please indicate that in the not applicable column.
NOTE: For organizations that are seeking to become Coordination-Only D-SNPs that meet the definition for AIPs at 42 CFR 422.561, in addition to uploading the state Medicaid agency contract (SMAC) and the corresponding matrices, please upload documentation showing the contractual relationship (if applicable) between your organization’s Medicaid product and the state, or the Medicaid managed care organization that holds the contract with the state, and documentation identifying the covered services.
HIDE, FIDE, and AIP Contract Requirements MATRIX
Contract Number (e.g. H-XXXX): _________________________
PBP(s):
Date:
State:
Coverage: LTC____ BH____Both_____
Contract Provision |
Page Number(s) |
Section Number |
Not Applicable |
NOTE: The page number and section number must be completed for organizations that answered “Yes” to Attestation 5 (required for any PBP seeking FIDE status).
If not applicable, please indicate that in the not applicable column. |
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438.400 and 438.402. (422.107(c)(9))
NOTE: All D-SNPs completing this table must complete this row. The page number and section number must be completed for organizations that answered “Yes” to Attestation 5 (required for any PBP seeking FIDE status). If not applicable, please indicate that in the not applicable column. |
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NOTE: Page number and section number must be completed for organizations seeking HIDE or FIDE SNP designations.
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NOTE:
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NOTE: Page number and section number must be completed for organizations seeking HIDE or FIDE SNP designations.
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NOTE: Page number and section number must be completed for organizations seeking HIDE or FIDE SNP designations.
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NOTE:
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NOTE: Page number and section number must be completed for 10, 11, or 12 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation. |
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NOTE: Page number and section number must be completed for 10, 11, or 12 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation. |
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NOTE: Page number and section number must be completed for 10, 11, or 12 by organizations seeking applicable integrated plan status without a HIDE or FIDE designation. |
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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 C: Basic Dual Eligible Special Needs Plans State Medicaid Agency HIDE, FIDE, and AIP Contract Requirements Matrix |
Subject | PRA Pkg: Appendix C: DSNP SMAC HIDE, FIDE, & AIP Contract Requirements Matrix |
Author | CMS-MMCO |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |