Attachment 5 - CMS Certification Outcomes.pdf
PDF 82 KB Posted
- Attached to
- Nebraska Medicaid Enrollment Broker
- Solicitation number
- 125920 O3
- Issued by
- Nebraska
About this file
This is a CMS Certification Outcomes document detailing system requirements for the Nebraska Medicaid Enrollment Broker managed by the Nebraska Department of Health and Human Services. The document outlines eleven outcome metrics (MM01 through MM11) that establish the functional capabilities and compliance standards the enrollment broker system must meet under federal Medicaid regulations, primarily referenced in 42 CFR sections 438 and related state-specific procedures. Key required functionalities include auto-assignment of managed care enrollees to appropriate managed care organizations; notification of initial assignments with reasonable change periods; processing of member disenrollments per state procedures with effective dates in the first day of the second month following request; and maintenance of up-to-date fee-for-service and primary care case management provider directories with physician credentials, specialty information, contact details, acceptance of new patients, and cultural capabilities updated at least annually.
Of the eleven outcomes assessed, eight are fully applicable to the enrollment broker system, two are partially applicable with specified modifications, and one is not applicable. The partially applicable outcomes include MM02, which requires the system to maintain auto-assignment if members make no selection rather than confirming original assignment, and MM07 and MM09, which exclude in-person services and service area coverage information from the enrollment broker's responsibility. The non-applicable outcome MM06 reflects that the enrollment broker does not capture enrollee needs for Health Risk Assessments, which remain the responsibility of managed care organizations. Additionally, MM11 clarifies that network adequacy evaluation is conducted through Nebraska's EQRO vendor and MCO reports rather than through the enrollment broker system itself.
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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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