State Medicaid Agency Contract (SMAC) 2027 Frequently Asked Questions

• FAQs also available in Portable Document Format (PDF)

June 2026

Categories and Criteria for Eligibility

1. Will the Department publicly post which dual categories can enroll in the various D-SNPs offered in New York?
   The Department will update the duals webpage (Dual Eligible New Yorkers) to more clearly state which categories of duals can enroll in which D-SNPs.

Network Congruency

2. Does the Department plan to increase the 85% network congruency for FIDE and HIDE SNPs?
   The Department has no current plans to increase the 85% congruency requirement.
3. Will the Department share the network congruency attestation as soon as possible and outline in the 2027 SMAC Agreement what provider specialty and categories will be included in the 85% network congruency calculation?
   The Department will not require Plans to submit a network congruency attestation in calendar year 2026.
4. Please clarify what network congruency means. Specifically, is this intended to align with the 85% network overlap requirement referenced later in the document?
   Network congruency refers to the alignment between a Health Plan's Medicaid and Medicare network. A Health Plan offering FIDE SNP(s) and/or HIDE SNP(s) must ensure that 85% of its Medicaid provider networks overlaps with its Medicare provider network. The SMAC includes an additional requirement that such Health Plan must also ensure that 85% of its Medicaid provider network offering Supplemental Benefits overlaps with its Medicare provider network offering Supplemental Benefits.
5. Does the 85% network congruency apply to Coordination Only D-SNPs?
   No, as outlined in the SMAC, Coordination Only D-SNPs must follow network congruency requirements per CMS regulations.
6. The 2027 SMAC Agreement states: "Health Plan shall ensure that its Medicare and Medicaid participating provider networks are congruent in each service area covered by the D-SNP." Can the Department clarify whether the 85% network congruency applies to the total area/counties that the D-SNP is in?
   The 85% network congruency requirement applies to each county in which the D-SNP is approved to operate.

Integrated HRA

7. Does the UAS-NY satisfy the integrated HRA requirement for MAP? Does DOH intend to provide a plan-specific Medicaid HRA?
   No. The Uniformed Assessment System (UAS) serves to determine eligibility for certain long term care programs. The integrated health risk assessment (HRA) is conducted for newly enrolled Medicare Advantage members. The UAS does not meet the requirements for administration of an integrated HRA found at 422.101.
   
   DOH will provide further guidance on a plan-specific Medicaid HRA template in 2026.

Summary of Benefits Submission

8. A Department memorandum dated June 18, 2025, regarding "Medicaid Managed Care-Specific Information within Medicare Advantage D-SNP Marketing and Communications", states that its guidance applies to Medicaid Managed Care Plans (MMCP). Per the 2027 SMAC, the Summary of Benefits requirement does not specify that its applicability is limited to MMCPs. Can the Department confirm if this requirement applies to all D-SNPs, including Coordination-Only D-SNPs?
   Yes, the Summary of Benefits requirement applies to all D-SNP types including FIDE, HIDE and Coordination Only D-SNPs. Health Plans are required to submit marketing and/or member materials to DOH to ensure the accuracy of any Medicaid benefits or policy information described.

AIP Designation

9. Can the Department clarify Applicable Integrated Plan (AIP) designation for IB Dual HIDE-SNP products? Is it correct that if the box that says, "Health Plan attests that it operates a D-SNP that enrolls both Medicaid Managed Care and FFS Medicaid Dual Eligibles," is checked then the HIDE-SNP is not designated as an AIP?
   Correct. If the Health Plan operates a D-SNP that enrolls both Medicaid Managed Care and FFS Medicaid Dual Eligibles, it does not quality as an AIP. However, a D-SNP that exclusively enrolls individuals in an IB-Dual (HIDE) or Medicaid Advantage Plan (FIDE) is designated as an AIP.
10. Can the Department provide clarification regarding the AIP designation specific to the Managed Care Organizations ("MCO") with an Integrated Benefits for Dually Eligible Enrollees Program ("IB-Dual") Highly Integrated Dual Eligible Special Needs Plan ("HIDE SNP") product?
    An IB-Dual HIDE SNP product is considered an Applicable Integrated Plan (AIP) when it limits enrollment to beneficiaries enrolled in an affiliated Medicaid managed care organization as described in 42 CFR 422.561.

Service Area Expansion

11. Please advise the specific CMS documentation the Department requires for the MCO to demonstrate the Service Area Expansion to CMS. Would a listing of the service area expansion counties from the Health Plan Management System (HPMS) module suffice?
    DOH recommends Plans contact their CMS Plan Manager to confirm the required documentation.
12. May a plan provide the CMS approval of the bid as confirmation of the final CMS approval of the service area? This approval is typically received in August or September each year.
    Yes. This would be acceptable to DOH.

Integrated Member ID Card

13. Does the Integrated Member ID card requirement apply to non-exclusively aligned D-SNPs?
    At this time, the Integrated Member ID card requirement only applies to Applicable Integrated Plans (AIP). It does not apply to non-exclusively aligned D-SNPS.

Model of Care

14. Can the Department update the 2027 SMAC Agreement to clarify that plans do not need to submit the MOC to the Department if there are no changes or updates? This aligns with the MOC submission guidance in the CY2026 SMAC FAQ.
    Health Plans are required to submit new CMS-approved Models of Care (MOC ) or any updates to an approved MOC to the Department within 30 days of approval. Health Plans are not required to submit the MOC to the Department if the MOC has not been updated by the Plan or approved by CMS within the past 30 days.
15. Does the MCO have the option of using similar Accountable Health Communities (AHC) screening tool questions if it captures similar responses to the AHC screening tool used by the Social Care Networks (SCN) and the member's social needs across housing stability, food security, and access to transportation?
    Questions related to the Accountable Health Communities screening tool requirements should be directed to sdh@health.ny.gov.

Coordination of Benefits for Medicare Advantage Supplemental Benefits

16. The language appears to indicate that the health plan is per se the primary payer in all circumstances, which is not necessarily the case. Medicaid may statutorily be primary payer. The service/item may not be payable under the Medicare Advantage benefit rules, etc.
    DOH has modified the language in this section of the 2027 SMAC accordingly.

Reporting

17. Can DOH clarify that the Hospital and Skilled Nursing Facility Reporting applies to Coordination only D-SNP and HIDE-SNP plans in CY2027? The Notification of Hospital and Skilled Nursing Facility Admission states that "D-SNPs that do not meet a FIDE or HIDE designation shall provide…" so we assume this to applicable to Coordination only D-SNP plans. However, this requirement is not listed in the Coordination only D-SNP Requirements section. In addition, the HIDE D-SNP requirements indicates that the plan should continue with the hospital and SNF reporting, which contradicts with Section III.
    DOH has clarified in the SMAC that the Hospital and SNF Reporting requirement applies to Coordination Only D-SNPs and HIDE SNPs aligned with a Managed Long Term Care Partial (MLTCP).

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