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 file contains the CMS Certification Outcomes for the Nebraska Medicaid Enrollment Broker system, outlining the mandatory and state-specific requirements that the system must satisfy according to federal regulatory standards and state procedures. The document details eleven key outcomes (MM01-MM11) that align with 42 CFR provisions and state Medicaid guidelines, each mapped to specific regulatory sources. The outcomes encompass critical enrollment broker functions including auto-assignment of managed care enrollees to managed care organizations, member notification and choice provisions, disenrollment procedures and timelines, notification requirements, information sharing protocols, multi-channel beneficiary communication, content provision through state websites, potential enrollee education, provider directory maintenance and updates, and network adequacy evaluation mechanisms.
Of the eleven outcomes specified, six are noted as fully applicable to Nebraska's Enrollment Broker system (MM01, MM03, MM04, MM05, MM08, MM10), three are partially applicable with modifications to federal requirements (MM02, MM07, MM09), and two are not applicable to the Enrollment Broker's scope (MM06, MM11). For outcomes designated as not applicable, the document clarifies that responsibilities fall to other entities: Health Risk Assessments are managed by Managed Care Organizations rather than the Enrollment Broker, and network adequacy evaluation is conducted through Nebraska's External Quality Review Organization vendor and reports provided directly by the MCOs. The certification framework ensures the Enrollment Broker system operates within established federal and state regulatory parameters while delineating clear functional boundaries between the broker and managed care organizations.
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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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