ACAP Comment Letter on Information Collection Request for Part C Benefits BY2021

November 12, 2019

Administrator Seema Verma
Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201

Submitted via electronic submission system

RE: Proposed Information Collection Request CMS–10237 (OMB control number: 0938–0935)

Dear Administrator Verma:

Thank you for the opportunity to provide comment on the Centers for Medicare and Medicaid Services (CMS)’s proposed Information Collection Request with respect to the Application for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits for Benefit Year 2021.

ACAP is an association of 69 not-for-profit, community-based Safety Net Health Plans located in 30 states. Our member plans provide coverage to over twenty million individuals enrolled in Medicaid, Children’s Health Insurance Program (CHIP) and Medicare Advantage Dual-Eligible SNPs. Nationally, ACAP plans serve approximately one-third of all Medicaid managed care enrollees. Eighteen of our plans are D-SNPs and 11 of our plans participate in the Financial Alignment Demonstration.

As required by the Bipartisan Budget Act (BBA) of 2018, all dual-eligible special needs plans (D-SNPs) must meet new standards for integration by 2021 along with a certain subset of D-SNPs that must implement a newly unified set of grievances and appeals processes. CMS promulgated the initial series of implementing regulations for these requirements via CMS-4185 Policy and Technical Changes to the Medicare Advantage Program for BY2020 and BY2021 and now seeks to modify the Application for Medicare Part C Plans to Provide Part C Benefits for BY2021 per these requirements.

We are supportive of both Congress’ intent through the BBA and the Administration’s efforts to advance integration through D-SNPs, along with broader efforts to advance integrated plan products. We are generally supportive of the process and manner in which CMS seeks information from plans to verify their compliance with the BBA’s requirements, but we would ask that CMS make accommodations for the varying levels of progress states may make in producing and finalizing updated state Medicaid agency contracts (SMACs), given the timeframe for final approval of D-SNP operations for BY2021.

As outlined in Section 50311(b) of the BBA, Congress required D-SNPs to meet one of three new requirements for heightened D-SNP integration by 2021 through 2025. CMS interpreted these requirements as meaning that a plan must either:

  • be designated a fully-integrated D-SNP (FIDE-SNP);
  • a highly integrated D-SNP (HIDE-SNP); or
  • have a contract with the state to specify an information sharing process for certain dual-eligibles when they are admitted to a hospital or skilled nursing facility.

Therefore, all D-SNPs that are not HIDE-SNPs or FIDE-SNPs must meet the third requirement. CMS provided significant flexibilities to states in constructing the parameters of this information sharing requirement. Given the upcoming deadlines for the CY2021 approval process, we are working diligently with our state partners to ensure all SMACs are compliant with this third requirement. However, given the variation in state-based levels of integration, this requirement may take longer to get fully incorporated into SMACs in some states.

Request for Documentation Flexibility

Given the current level of state-based variation in integrated care, we would ask that CMS work collaboratively with plans during this inaugural application process to help remedy issues where plans and states have agreed to meet D-SNP requirements, but may not have included extensive details of those requirements in their SMACs.  For example, we would ask CMS to be supportive of supplemental information that could provide greater detail on SMAC requirements that may be less detailed.

Additionally, separate from the BBA’s requirements, CMS chose to interpret for the first time the phrase “arrange for benefits.” Under 42 CFR § 422.107(c)(1)(i), CMS explains that “for all enrollees who are eligible for Medicaid services, the D-SNP must fulfill its statutory responsibility to arrange for the provision of Medicaid benefits by facilitating a beneficiary’s meaningful access to such benefits.” Subsequently, CMS now seeks information on which contract provisions describe the mechanisms for coordinating Medicaid services across FFS and managed care. We understand the need for this information and would like to point out that it may not be specifically described in the SMAC, but rather in other materials submitted to the state Medicaid agency. Therefore, we would ask that CMS approve broad contract language for this requirement with the understanding that plans will be able to provide supplemental material describing the mechanisms for coordination.


We would like to reiterate our support for the move towards more integrated systems of care for the dual-eligible population. Congress’ and the Administration’s actions through the BBA of 2018 represent a positive step forward in advancing integration to improve outcomes and provide more efficient care for dual-eligibles.

ACAP is prepared to assist with additional information, if needed. If you have any questions, please do not hesitate to contact Christine Aguiar Lynch at (202) 204-7519 or


Margaret A. Murray
Chief Executive Officer

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