Attachment 5 - CMS Certification Outcomes.docx
DOCX document 29 KB Posted
- Attached to
- Nebraska Medicaid Enrollment Broker
- Solicitation number
- 125920 O3
- Issued by
- Nebraska
About this file
This document outlines CMS Certification Outcomes for Nebraska's Medicaid Enrollment Broker system, detailing compliance requirements across eleven outcome areas aligned with federal regulations under 42 CFR and state-specific provisions. The outcomes define system functionality requirements for managed care enrollment operations, including auto-assignment of enrollees to managed care organizations, member notification and choice periods, disenrollment procedures, and information distribution through multiple channels. The Enrollment Broker system is required to maintain up-to-date fee-for-service and primary care case-management provider directories updated at least annually, containing physician/provider names, specialties, contact information, acceptance of new Medicaid patients, cultural capabilities, and supported languages.
The document indicates varying levels of applicability for each outcome. Six outcomes are fully applicable to the Enrollment Broker system (MM01, MM03, MM04, MM05, MM08, MM10), three are partially applicable with modifications to federal standards (MM02, MM07, MM09), and two are not applicable to the Enrollment Broker's scope (MM06 and MM11). Notably, health risk assessments and enrollee needs capture are assigned to Managed Care Organizations rather than the Enrollment Broker, and network adequacy evaluation is conducted through Nebraska's EQRO vendor and MCO-provided reports rather than through the Enrollment Broker system itself. These outcome definitions establish the baseline functional and regulatory requirements the Enrollment Broker must meet for CMS certification and ongoing state Medicaid operations.
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Text version
125920 O3 Nebraska Medicaid Enrollment Broker Attachment 5 – CMS Certification Outcomes
Outcome Reference #
Outcome Description CMS Required Regulatory Source(s) or State Specific
Outcome Applicability
| MM01 |
| The system auto-assigns managed care enrollees to appropriate managed care organizations, per state and federal regulations. |
| CFR 42 438.54 |
| MM01 is fully applicable. |
| MM02 |
| The system sends notice, or facilitates, to the enrolled member with an initial assignment, a reasonable period to change the selection, and appropriate information needed to make an informed choice. If no selection is made, the system either confirms the original assignment, or assigns the member to FFS. |
| CFR 42 438.10, 438.54 |
| MM02 is partially applicable. |
The system sends notice, or facilitates, to the enrolled member with an initial assignment, a reasonable period to change the selection, and appropriate information needed to make an informed choice. If no selection is made, the system maintains the auto-assignment.
| MM03 |
| The system disenrolls members at the request of the plan and in accordance with state procedures. |
| 42 CFR 438.56(b) (c), and (d) |
| MM03 is fully applicable. |
| MM04 |
| Disenrollments are effective in the system the first day of the second month following the request for disenrollment. |
42 CFR 438.56(e)
MM04 is fully applicable.
| MM05 |
| The system notifies enrollees of their disenrollment rights at least 60 days before the start of each enrollment period. This notification is in writing. |
42 CFR 438.56(f) MM05 is fully applicable.
| MM06 |
| To prevent duplication of activities, enrollee's needs are captured by the system so that MCOs, PIHPs, and PAHPs can see and share the information (in accordance with privacy controls). |
42 CFR 438.208(b) MM06 is not applicable.
The Enrollment Broker does not capture enrollee needs. The MCOs are responsible for Health Risk Assessments.
| MM07 |
| The system allows beneficiaries or their representative to receive information through multiple channels including phone, Internet, in-person, and via auxiliary aids and services. |
42 CFR 438.71
MM07 is partially applicable.
The system allows beneficiaries or their representative to receive information through multiple channels including phone, Internet, and via auxiliary aids and services.
| MM08 |
| The state provides content required by 42 CFR 438.10, including but not limited to definitions for managed care and enrollee handbook, through a website maintained by the state. |
42 CFR 438.10(c) MM08 is fully applicable.
| MM09 |
| Potential enrollees are provided information about the state's managed care program when the individual become eligible or is required to enroll in a managed care program. The information includes, but is not limited to the right to disenroll, basic features of managed care, service area coverage, covered benefits, and provider directory and formulary information. |
42 CFR 438.10(e) MM09 is partially applicable.
Potential enrollees are provided information about the state's managed care program when the individual become eligible or is required to enroll in a managed care program. The information includes, but is not limited to the right to disenroll, basic features of managed care, covered benefits, and provider directory.
| MM10 |
| The system maintains an up-to-date (updated at least annually) fee-for-service (FFS) or primary care case-management (PCCM) provider directory containing the following: |
- Physician/provider
- Specialty
- Address and telephone number
- Whether the physician/provider is accepting new Medicaid patients (for PCCM providers), and the physician/provider's cultural capabilities and a list of languages supported (for PCCM providers).
Section 1902(a)(83), 1902(mm), SMD # 18-007 MM10 is fully applicable.
| MM11 |
| The system captures enough information such that the state can evaluate whether members have access to adequate networks. (Adequacy is based on the state's plan and federal regulations). |
42 CFR 438.68
MM11 is not applicable.
The Enrollment Broker system does not capture information such that the state can evaluate whether members have access to adequate networks. Network adequacy is evaluated through Nebraska's EQRO vendor. Adequacy reports are also provided by the MCOs.
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