Attachment 5 - CMS Certification Outcomes.docx

This is a CMS Certification Outcomes attachment for the Nebraska Medicaid Enrollment Broker contract managed by the State of Nebraska Department of Health and Human Services. The document outlines eleven outcome requirements (MM01 through MM11) that the enrollment broker system must satisfy to meet federal and state regulatory standards. Key outcomes include the system's ability to auto-assign managed care enrollees to appropriate managed care organizations per 42 CFR 438.54, send enrollment notices with reasonable selection periods and informed choice information per 42 CFR 438.10 and 438.54, process member disenrollments at plan request in accordance with state procedures per 42 CFR 438.56, and provide notice of disenrollment rights at least 60 days before each enrollment period. Additionally, the system must maintain updated fee-for-service or primary care case-management provider directories updated at least annually containing physician information, specialties, contact details, acceptance of new patients, and cultural capabilities per Section 1902(a)(83) and 1902(mm).

The outcomes document specifies applicability determinations for each requirement, with six marked as fully applicable, three as partially applicable, and two as not applicable to the enrollment broker function. Notably, the system is not responsible for capturing enrollee needs for Health Risk Assessments—this responsibility remains with the managed care organizations. Network adequacy evaluation is also excluded from the enrollment broker's scope, as this function is performed through Nebraska's External Quality Review Organization (EQRO) vendor and reports provided directly by the managed care organizations. The partially applicable outcomes include information delivery through multiple channels (excluding in-person services) and provision of managed care program information excluding service area coverage and formulary information to potential enrollees.