Crosswalk (60-day)

CMS-10796 Collection Instrument Change Crosswalk: Changes to D-SNP State Medicaid
Agency(ies) Contract(s)
Appendix A: Attestations
Location of Change
Descriptive paragraph
under title

Question #1

Question #2

Question #3

Question #4

Question #5

Description of
Change
Removed language.

Edited language by
removing date,
discussion of
evergreen contracts,
and adjusting for
other minor editorial
issues.
Edited language by
removing date,
discussion of
evergreen contracts,
and adjusting for
other minor editorial
issues.
Edited language by
removing date and
adjusting for other
minor editorial
issues.
Edited language by
removing date and
adjusting for other
minor editorial
issues.
Edited language by
removing date and
information in the
note at the bottom of
the cell, changing the
name of the matrix,
and adjusting for

Reason for Change

Effect on
Burden
No effect

Adherence to CMS
communication standards and
clarifying or removing
redundant, not up-to-date, or
confusing information.
Adherence to CMS
No effect
communication standards and
clarifying redundant or
confusing information.

Adherence to CMS
No effect
communication standards,
clarifying redundant or
confusing information, and
adding language to clarify
how the attestation should be
completed.
Adherence to CMS
No effect
communication standards,
clarifying redundant or
confusing information, and
adding language to clarify
how the attestation should be
completed.
Adherence to CMS
No effect
communication standards and
clarifying redundant or
confusing information.
Adherence to CMS
No effect
communication standards and
clarifying or removing
redundant, not up-to-date, or
confusing information.

Question #6

other minor editorial
issues.
Added question #6

Added question to explain
requirement for organizations
seeking HIDE, FIDE, or AIP
status to 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, per 42 CFR 422.2.

Adds burden,
as seen in
sections 12
and 15 of the
Supporting
Statement.

Appendix B: Basic D-SNP State Medicaid Agency Contract Requirements Matrix
Location of Change
Title

Descriptive paragraph
under title

Required information
under section titled
“State Contract
Requirements”
First required item in
table

Description of
Change
Changed “D-SNP State
Medicaid Agency
Contract Matrix” to
“Basic D-SNP State
Medicaid Agency
Contract Requirements
Matrix.”
Added descriptive
language, corrected
location of where to
find further
information, and
amended language.
Removed section for
applicant to include
plan name and added
section for applicant to
include contract
number.
Added requirement for
applicants to include
the location of
signatures of the state
and plan
representatives
indicating that this
contract is in effect for

Reason for Change
Updated title for clarity.

Effect on
Burden
No effect

Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.

No effect

The language that was
removed was no longer
necessary, and the
language that was added
will help reviewers in
reviewing applications.
Signatures are required in
order for the contract to be
in effect, and the language
that was added showing
the location of the
signatures will help
reviewers in reviewing
applications.

No effect

No effect

Question #1

Question #2

the upcoming contract
year.
Language added
requiring applicants to
identify the legal entity
that holds the SMAC
contract with the state.
Question #2 was
question #1.

Question #3

Question #3 was
question #2.

Question #4

Added required
element to include
language on age
restrictions on
enrollment limitations.
Added required
element to include
language on
geographic restrictions
on enrollment
limitations.
Made minor editorial
changes.

Question #5

Question #6

Question #7

Question #7 was
question #4.

Question #8

Question #8 was
question #5.

Question #9

Question #9 was
question #6.

Question #10

Question #10 was
question #7.

Question #11

Question #11 was
question #8.

Question #14

Made minor editorial
changes.

The language that was
added will help reviewers
in reviewing applications.

No effect

Questions were rearranged
to as new questions were
added.
Questions were rearranged
to as new questions were
added.
The language that was
added will help reviewers
in reviewing applications.

No effect

The language that was
added will help reviewers
in reviewing applications.

No effect

Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Questions were rearranged
to as new questions were
added.
Questions were rearranged
to as new questions were
added.
Questions were rearranged
to as new questions were
added.
Questions were rearranged
to as new questions were
added.
Questions were rearranged
to as new questions were
added.
Adherence to CMS
communication standards

No effect

No effect
No effect

No effect
No effect
No effect
No effect
No effect
No effect

Question #15

Language was added.

Question #16

Made minor editorial
changes.

Question #17

Made minor editorial
changes.

and clarifying or removing
redundant, not up-to-date,
or confusing information.
Language was added to
clarify the question.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.

No effect
No effect

No effect

Appendix C: HIDE, FIDE, and AIP Contract Requirements Matrix
Location of Change
Title

Descriptive paragraph
under title

Subtitle

Required information
under subtitle

Description of
Change
Changed title from
“Special Needs Plan
(SNP) Contract Status
Review Matrix” to
“HIDE, FIDE, and AIP
Contract Requirements
Matrix.”
Made minor editorial
changes, added a
sentence describing
which applicants must
complete the matrix,
and added language
describing requirement
for showing
contractual relationship
between parties.
Changed title from
“Special Needs Plan
(SNP) Contract Status
Review Matrix” to
“HIDE, FIDE, and AIP
Contract Requirements
Matrix.”
Removed section for
applicant to include

Reason for Change
Updated title for clarity.

Effect on
Burden
No effect

Adherence to CMS
No effect
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information, as
well as adding descriptive
information.

Updated title for clarity.

No effect

The language that was
removed was no longer

No effect

Question #1

plan name and added
section for applicant to
include contract
number. Removed
section for applicant to
provide the name of
the organization that
holds the Medicaid
managed care contract.
Made minor editorial
changes and added
clarifying language.

Question #2

Made minor editorial
changes and added
clarifying language.

Question #3

Made minor editorial
changes.

Question #4

Made minor editorial
changes.

Question #5

Made minor editorial
changes.

Question #6

Made minor editorial
changes.

Question #7

Made minor editorial
changes.

necessary, and the language
that was added will help
reviewers in reviewing
applications.

Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information, as
well as adding descriptive
information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information, as
well as adding descriptive
information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing

No effect

No effect

No effect

No effect

No effect

No effect

No effect

Question #8

Made minor editorial
changes.

Question #9

Made minor editorial
changes.

Question #10

Made minor editorial
changes.

Question #11

Made minor editorial
changes.

Question #12

Made minor editorial
changes.

redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.
Adherence to CMS
communication standards
and clarifying or removing
redundant, not up-to-date,
or confusing information.

No effect

No effect

No effect

No effect

No effect