DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
DATE:   November 14, 2019 
FROM:  Calder Lynch, Acting Deputy Administrator  and Director 
Center for Medicaid and CHIP Services 
 
Tim Engelhardt,  Director 
    Medicare-Medicaid  Coordination  Office   
 
SUBJECT:   Medicare-Medicaid  Integration  and Unified  Appeals and Grievance  Requirements 
for State Medicaid Agency Contracts with Medicare Advantage  Dual Eligible 
Special Needs Plans (D-SNPs) for Contract Year 2021  
Introduction 
Dual Eligible  Special Needs Plans (D-SNPs) are Medicare Advantage (MA) plans that are 
specifically  designed to integrate  and coordinate care for dually  eligible  individuals  by focusing 
on enrollment  and care management  for this population.  As of September 2019, approximately 
2.7 million  dually  eligible  individuals  (one out of every five dually  eligible  individuals)  were 
enrolled in one of the 480 D-SNPs.1 
The Bipartisan  Budget Act (BBA) of 2018 strengthened  D-SNP Medicare-Medicaid  integration 
requirements  and unified  Medicare and Medicaid grievance  and appeals procedures for some D-
SNPs beginning  in 2021. On April 16, 2019, CMS finalized  rules (hereafter  referred to as the 
April 2019 final  rule) implementing  these new statutory provisions.2  States play an important 
role in D-SNP implementation  of these requirements.  This bulletin  contains  information  for 
states to consider when updating  their Contract Year (CY) 2021 contracts with D-SNPs 
(submitted  to CMS in July 2020). This bulletin  also highlights  important  information  that states 
need to ensure that D-SNPs in their markets meet the new requirements  beginning  in CY 2021. 
We strongly recommend states use the information  in this bulletin to engage with D-SNPs 
on these new requirements as soon as possible.  
Background 
Beneficiaries  dually  eligible  for Medicare and Medicaid can face significant  challenges  in 
navigating  the two programs, which include  separate or overlapping  benefits  and administrative 
processes. Fragmentation  in care delivery  can result in a lack of coordination,  which may lead to:  
                                                                 
1 Centers for Medicare & Medicaid Services (2019, September). SNP Comprehensive Report. Retrieved from 
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/MCRAdvPartDEnrolData/Special-Needs-Plan-SNP-Data.html.   
2 See: CMS-4185-F,  the Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare 
Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid 
Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021 final rule. Retrieved from 
https://www.govinfo.gov/content/pkg/FR-2019-04-16/pdf/2019-06822.pdf.  CMCS Informational  Bulletin   Page 2 
(1) missed opportunities  to provide appropriate, high-quality  care and improve health, and (2) 
undesirable  outcomes, such as avoidable hospitalizations  and a poor beneficiary  care experience. 
Misalignments  between Medicare and Medicaid also can result in weakening  safeguards for 
beneficiaries.  For example, the grievance  and appeal processes for both programs take broadly 
similar  approaches, but operate independently  with subtle misalignments.  For dually  eligible 
individuals,  these separate processes result in confusion  over which  program is covering  an item 
or service and how to file a grievance  or appeal.  
Advancing  policies  and programs that integrate  processes and care for dually  eligible  individuals 
is one way in which CMS seeks to address this fragmentation.  As discussed in our December 19, 
2018, State Medicaid Director Letter, Ten Opportunities  to Better Serve Individuals  Dually 
Eligible  for Medicaid  and Medicare, 3 there are several ways in which states are currently  using 
the D-SNP platform  to advance such integration,  including  requiring  that Medicaid managed 
care organizations  (MCOs) offer an affiliated  D-SNP. This approach  used by a number of 
states, including  Arizona,  Hawaii, Idaho, Massachusetts,  Minnesota, New Jersey, New Mexico, 
Pennsylvania,  Tennessee,  and Virginia   requires Medicaid MCOs serving  dually  eligible 
individuals  to offer an affiliated  D-SNP. This ensures that these enrollees  have the option of 
receiving  the full  array of Medicare and Medicaid benefits through  a single  delivery  system, 
thereby improving  care coordination,  quality  of care, and beneficiary  satisfaction,  and reducing 
administrative  burden.  
Medicaid MCOs that have an affiliated  D-SNP that is offered by the same organization  and 
meets other CMS requirements  regarding  provision  of Medicaid benefits  are known as fully 
integrated  D-SNPs (FIDE SNPs), described in more detail in the Integration  Requirements 
section of this bulletin.   Highly  integrated  D-SNPs (HIDE SNPs) are less integrated  but provide 
coverage of Medicaid long-term  services and supports (LTSS), behavioral  health services,  or 
both, under a capitated contract between the state Medicaid agency and the MA organization,  the 
MA organizations  parent organization,  or another entity owned by the MA organization  or its 
parent organization. 
While there is mounting  evidence  that highly  integrated  managed care programs perform well on 
quality  of care indicators  and enrollee satisfaction,4  the majority  of D-SNP enrollees  are not 
enrolled in these highly  integrated  arrangements.  The new D-SNP requirements  added by the 
                                                                 
3 See: https://www.medicaid.gov/federal-policy-guidance/downloads/smd18012.pdf 
4 See: Kim, H., Charlesworth, C.J., McConnell, K.J., Valentine, J.B., and Grabowski, D.C. (2017, November 15). 
Comparing Care for Dual-Eligibles Across Coverage Models: Empirical Evidence From Oregon. Retrieved from 
http://journals.sagepub.com/doi/abs/10.1177/1077558717740206;  Anderson, W.L., Feng, Z., & Long, S.K. (2016, 
March 31). Minnesota Managed Care Longitudinal Data Analysis, prepared for the U.S. Department of Health and 
Human Services Assistant Secretary for Planning and Evaluation (ASPE). Retrieved from 
https://aspe.hhs.gov/report/minnesota-managed-care-longitudinal-data-analysis; Health Management Associates 
(2015, July 21). Value Assessment of the Senior Care Options (SCO) Program. Retrieved from 
http://www.mahp.com/wp-content/uploads/2017/04/SCO-White-Paper-HMA-2015_07_20-Final.pdf;  and Medicare 
Payment Advisory Committee (2012, June 16). Care coordination programs for dual-eligible beneficiaries. In 
June 2012 Report to Congress: Medicare and Health Care Delivery System. Retrieved from 
http://www.medpac.gov/docs/default-source/reports/chapter-3-appendixes-care-coordination-programs-for-dual-
eligible-beneficiaries-june-2012-report-.pdf?sfvrsn=0.  CMCS Informational  Bulletin   Page 3 
BBA of 2018 present new opportunities  for states to further  Medicare and Medicaid integration 
using  D-SNPs as a platform. 
Summary  of New D-SNP Requirements 
We summarize  the D-SNP requirements  that CMS codified in the April 2019 final  rule below. 
Integration Requirements 
Starting  in CY 2021, D-SNPs must meet the new Medicare-Medicaid  integration  criteria in at 
least one of the following  ways listed in the table below: 
 
Three Ways of Meeting the D-SNP Integration Requirements  
 
1. D-SNP meets CMS  Provides Medicare and Medicaid benefits  under a single  entity 
requirements to be  that: 
designated as a FIDE SNP 
  Has an MA contract with CMS; and  
  Has a Medicaid MCO contract with a state;  
  Has coordinated care delivery  and coordinates or integrates 
certain administrative  functions;  and 
  Provides coverage, consistent  with state policy, of Medicaid 
benefits,  including:   
  Long-term services and supports (LTSS); and 
o
  Nursing  facility  services for at least 180 days per plan 
o
year 
2. D-SNP meets CMS  Provides Medicare benefits  and:  
requirements to be 
designated as a HIDE SNP    Has an MA contract with CMS; and 
  Provides coverage of Medicaid LTSS and/or behavioral 
health services, consistent  with state policy,  under a 
capitated contract between the state Medicaid agency and:  
  The MA organization;  or 
o
  The MA organizations  parent organization;  or 
o
  Another entity owned by the MA organization/parent 
o
organization   
3. D-SNP notifies the state  Has a contract with the state that specifies  a process for 
(or state designees) of  notifying  the state, or the states designee(s),  of hospital or 
hospital or SNF  skilled  nursing  facility  (SNF) admissions  for at least one 
admissions for at least one  designated group of high-risk  individuals,  for the purpose of 
group of high risk  care coordination  of Medicare and Medicaid covered services 
enrollees  during  a transition  of care. The state Medicaid agency must 
establish  the timeframes  and method(s) by which notice is 
provided. 
  CMCS Informational  Bulletin   Page 4 
States whose D-SNPs provide enrollees with capitated Medicaid benefits   either directly  or 
indirectly   may be particularly  interested in the table below, which provides more detail on the 
similarities  and differences  between FIDE SNPs and HIDE SNPs. States can make substantial 
progress toward integrated  care using  the D-SNP platform  whether they contract with FIDE 
SNPs or HIDE SNPs.  However, one key difference  between FIDE SNPs and HIDE SNPs 
beyond their level  of integration  is that FIDE SNPs may qualify  for a frailty  adjustment  to their 
Medicare payment  from CMS if specific  criteria are met, whereas HIDE SNPs are not eligible 
for that payment adjustment. 
Attributes of FIDE SNPs and HIDE SNPs 
 
  FIDE SNP  HIDE SNP 
Must have a contract with the state  Yes  No   
Medicaid agency that meets the 
requirements of a managed care 
organization  as defined in section 
1903(m) of the Act. 
May provide coverage of Medicaid  No  Yes 
services via a prepaid inpatient 
health plan (PIHP) or a prepaid 
ambulatory  health plan (PAHP). 
Must provide coverage of  Yes  No. The state Medicaid 
applicable Medicaid benefits  contract may be with:  (1) 
through the same entity that  the MA organization 
contracts with CMS to operate as  offering  the D-SNP; (2) 
an MA plan.  the MA organizations 
parent organization;  or (3) 
another entity owned and 
controlled  by the MA 
organizations  parent 
organization. 
Must have a capitated contract  Yes  No, if the capitated 
with the state Medicaid agency to  contract otherwise covers 
provide coverage of LTSS,  behavioral  health services.  
consistent with state policy. 
Must have a capitated contract  No.  Complete carve-out  No, if the capitated 
with the state Medicaid agency to  of behavioral  health  contract otherwise covers 
provide coverage of behavioral  coverage by the state  LTSS.   
health services, consistent with  Medicaid agency is 
state policy.  permitted.   
Must have a capitated contract  Yes  No 
with the state Medicaid agency to 
provide coverage of a minimum  of 
180 days of nursing facility services 
during the plan year. 
  CMCS Informational  Bulletin   Page 5 
Unified Appeals and Grievance Processes 
Certain D-SNPs and affiliated  Medicaid managed care plans  specifically,  those with 
exclusively  aligned  enrollment  as described in more detail in the Unified Appeals and 
Grievance  Requirements  for FIDE SNPs and HIDE SNPs with Exclusively  Aligned  Enrollment 
section of this bulletin   must implement  unified  Medicare and Medicaid grievance  and plan-
level appeals processes starting  in CY 2021. For these plans and their enrollees,  implementation 
of the requirements  in the April 2019 final  rule will provide simpler,  more straightforward 
grievance  and appeals processes. 
State Medicaid Agency Contract and Operational Changes 
All D-SNPs must have executed contracts with applicable  state Medicaid agencies, sometimes 
referred to as the State Medicaid Agency Contract (SMAC). This section describes the D-SNP 
contract with the state and operational  changes D-SNPs need to implement,  in collaboration  with 
state Medicaid agencies, to operate in CY 2021 and beyond. The first subsection  describes 
requirements  that apply to all D-SNPs.  Subsequent subsections  describe requirements  that apply 
only to certain subsets of D-SNPs. 
Requirements for all D-SNPs 
D-SNPs are required to submit to CMS a contract with each state in which they seek to operate 
for the upcoming  contract year by the first Monday in July.5 CY 2021 contracts must be 
submitted  to CMS by July 6, 2020. The April 2019 final  rule revised some of the minimum  state 
contract requirements  that apply to all D-SNPs and added new requirements  for some D-SNPs.  
To comply with these requirements  for CY 2021, D-SNPs will  need to work with state Medicaid 
agencies in advance of July 2020. (See the Key Dates for States section of this bulletin  for 
more information.)  The table below highlights  these changes to the minimum  state contract 
elements. 
The state D-SNP contract must document: 
1.  Revised:  The D-SNPs: (1) responsibility  to coordinate the delivery  of Medicaid benefits; 
and (2) if applicable, responsibility  to provide coverage of Medicaid services. 
2.  Revised: The category(ies)  and criteria for eligibility  for dually  eligible  individuals  to be 
enrolled under the D-SNP (e.g., conditions  of eligibility  under Medicaid, such as nursing 
home level of care and age or requirement  for D-SNP enrollees to enroll in a companion 
Medicaid plan to receive their Medicaid services). 
                                                                 
5 For further information see: Integrated Care Resource Center, Update on State Contracting with D-SNPs: The 
Basics and Meeting New Federal Requirements for 2021 (July 2019). Retrieved from: 
https://www.integratedcareresourcecenter.com/webinar/update-state-contracting-d-snps-basics-and-meeting-new-
federal-requirements-2021  CMCS Informational  Bulletin   Page 6 
The state D-SNP contract must document: 
3.  Revised: The Medicaid benefits  covered under a capitated contract between the state 
Medicaid agency and the MA organization  offering  the D-SNP, the D-SNPs parent 
organization,  or another entity  that is owned and controlled  by the D-SNPs parent 
organization. 
4.  The cost-sharing  protections covered under the D-SNP. 
5.  The identification  and sharing  of information  on Medicaid provider participation. 
6.  The verification  of enrollees  eligibility  for both Medicare and Medicaid. 
7.  The service area covered by the D-SNP. 
8.  The contract period for the D-SNP. 
9.  New: For a D-SNP that is not a FIDE SNP or HIDE SNP, a requirement  for notification  of 
hospital  or SNF admissions  for at least one designated  group of high  risk enrollees  (see 
the Information  Sharing  Requirements  for all D-SNPs except FIDE SNPs and HIDE 
SNPs section of this bulletin  for more information). 
10. New: For a D-SNP that is an applicable  integrated  plan, a requirement  for the use of the 
unified  appeals and grievance  procedures (see the Unified  Appeals and Grievance 
Requirements  for FIDE SNPs and HIDE SNPs with Exclusively  Aligned  Enrollment 
section of this bulletin  for more information). 
 
Information Sharing Requirements for all D-SNPs except FIDE SNPs and HIDE SNPs  
D-SNPs that do not contract with a state as FIDE SNPs or HIDE SNPs must include  the 
additional  minimum  state contract requirement  to specify a process to share information  on 
hospital  and SNF admissions  starting  for CY 2021. For the purpose of coordinating  Medicare 
and Medicaid-covered  services between settings  of care, the D-SNP contract with the state must 
describe: 
 
  The process whereby the D-SNP notifies,  or arranges for another entity  or entities  to 
notify,  the state (and/or the states designees) of hospital and SNF admissions  for at 
least one group of high-risk  full-benefit  dually  eligible  individuals,  identified  by the 
state; 
 
  The timeframe  and methods by which such notice is provided; and  
 
  The criteria for identifying  the high-risk  full-benefit  dually  eligible  individuals  for 
whom the notice is provided.  CMCS Informational  Bulletin   Page 7 
The April 2019 final  rule provides substantial  flexibility  for states. We encourage states to 
implement  the notification  requirement  in a manner that increases care coordination  during 
transitions  of care and builds on current infrastructure.  Examples  of state flexibility  include: 
  Choosing the manner in which  notification  occurs and how data is exchanged.  For 
example, in markets where there is existing  infrastructure  to leverage, such as a state 
health information  exchange (HIE), a state may elect an approach that requires data 
sharing  across a common platform.   
 
  Identifying  the group of high-risk  full-benefit  dually  eligible  individuals  for which the 
requirement  applies. For example, states can focus on dually  eligible  individuals  that 
receive home and community-based  services, behavioral  health services, or LTSS. 
There is no minimum  or maximum  size for the group of high-risk  enrollees  the state 
identifies.   
 
  Choosing which entity(ies)  receive the notification.  For example, a state could require 
that a D-SNP meet the notification  requirement  by notifying  a Medicaid MCO that 
serves dually  eligible  beneficiaries,  a Medicaid health home, or a home and 
community-based  services care coordinator. 
States can require a similar  notification  for FIDE SNPs and HIDE SNPs in the contract; 
however, this contract element is not necessary for FIDE SNPs and HIDE SNPs to meet 
Medicare-Medicaid  integration  criteria. 
Action Items for States: States can use the information  on minimum  state contract 
requirements  in this bulletin  to ensure any contract entered into with a D-SNP meets these 
revised standards.  
 
We also encourage states to engage stakeholders and relevant  D-SNPs as soon as possible to 
identify  the most cost effective  and least burdensome approaches and processes for the 
notification  requirement  that facilitate  care coordination.  CMS provides technical  assistance 
to states by sharing  best practices for this notification,  including  the resources highlighted  at 
the end of this bulletin. 
 
Unified Appeals and Grievance Requirements for FIDE SNPs and HIDE SNPs with 
Exclusively Aligned Enrollment 
A subset of FIDE SNPs and HIDE SNPs with exclusively  aligned  enrollment  must implement 
the unified  appeals and grievance  procedures described in 42 CFR 422.629  634 beginning  in 
2021. In the regulations,  we refer to these plans as applicable  integrated  plans,  defined at 42 
CFR 422.561 as FIDE SNPs or HIDE SNPs with exclusively  aligned  enrollment,  where state 
policy limits  the D-SNPs membership  to a Medicaid managed care plan offered by the same 
organization.  (In addition,  the Medicaid MCO that covers Medicaid benefits for the dually 
eligible  individuals  in the FIDE SNP or HIDE SNP with exclusively  aligned  enrollment  is also 
an applicable  integrated  plan subect to the unified  appeals and grievance  procedures under 42  CMCS Informational  Bulletin   Page 8 
CFR 438.210 and 438.402.) In such plans, one organization  is responsible  for managing 
Medicare and Medicaid benefits  for all D-SNP enrollees.   
The contracts with the states for these plans must include  a requirement  that the D-SNP uses the 
unified  appeals and grievance  procedures under 42 CFR 422.629  422.634, as well as 
conforming  Medicaid managed care rules at 438.210, 438.400, and 438.402. As specified  in the 
April 2019 final  rule, states have the discretion  to implement  standards different  than those 
established  in the final  rule if the state standards are more protective for enrollees, such as 
shorter timelines  for a plan to make a decision on an appeal (see 42 CFR 422.629(c)). Where 
states use this discretion  and implement  standards different  than those in 42 CFR 422.629   
422.634, the state must specify its requirements  in the D-SNP contract.   
Action Items for States: For states with D-SNPs subject to the new requirements,  beginning 
work to specify  any state-specific  standards in the D-SNP contract is crucial  in order to 
provide D-SNPs with notice of these standards and to ensure that we hold D-SNPs to the 
correct standards. States should also consider specifying  the additional  requirements  for 
unified  grievances  and appeals from 42 CFR 422.629 through  422.634, 438.210, 438.400, and 
438.402 in the Medicaid MCO contracts for the applicable  integrated  plans. 
 
 
Key Dates for States 
All D-SNPs are required to submit  a new contract with  the state (or an evergreen contract with a 
contract addendum) to CMS for each state in which they seek to operate in for CY 2021 by July 
6, 2020. This includes,  as applicable,  the new contract requirements  identified  in 42 CFR 
422.107(c) and (d) and summarized  in this bulletin.  Unlike in prior  years, D-SNPs with an 
evergreen contract cannot exclusively rely on the submission of a letter of good standing 
with a previously executed contract from their respective states to demonstrate compliance 
with 42 CFR 422.107. Therefore, we strongly encourage states and D-SNPs to begin 
discussing contract updates as soon as possible. The table below provides key dates and 
activities  for states and D-SNPs related to compliance  with the new requirements. 
Month/Year  Activity 
Fall 2019    States and D-SNPs begin drafting  changes needed to ensure 
state contracts meet new requirement 
  States plan for any needed MCO contract changes 
Winter 2020    States and D-SNPs identify  and create any new policies  and 
procedures needed in response to contract changes   
January 2020    CMS releases Contract Year 2021 MA (SNP) applications 
February 2020    SNP applications  (including  SNP service area expansion 
applications)  due to CMS  CMCS Informational  Bulletin   Page 9 
Month/Year  Activity 
Spring 2020    States and D-SNPs finalize  state contracts  
June 2020    D-SNPs not renewing  MA contracts notify  CMS in writing 
July 2020    D-SNPs submit  state contracts and related documents to CMS 
by July 6, 2020 
July/August 2020    D-SNPs work with CMS and states to address deficiencies  in 
contracts 
Summer 2020 - Fall 2020   States and D-SNPs finalize  policies  and procedures for CY 
2021   
August/September 2020    CMS sends D-SNP approval letters 
  D-SNPs provide Annual  Notice of Change and Evidence of 
Coverage (including  information  about any changes to 
grievances  and appeals procedures for applicable  integrated 
plans) to current enrollees 
January 1, 2021    Effective  date for most April 2019 final  rule provisions 
 
Resources 
The CMS Medicare-Medicaid  Coordination  Office (MMCO) works across CMS and with states 
to better serve dually  eligible  individuals,  including  through  efforts to better align  the Medicare 
and Medicaid programs through  integrated  service delivery  under D-SNPs. We are committed  to 
providing  technical  assistance to states and D-SNPs to help with implementation  of these new 
requirements.  MMCO sponsors the Integrated Care Resource Center (ICRC) to provide state-
specific  assistance to better understand the states dually  eligible  population,  assess options for 
improving  integration  of care, and navigate  aspects of the Medicare program that states can 
leverage to benefit Medicaid. To learn more and to contact ICRC, please visit 
http://www.integratedcareresourcecenter.com.  ICRC and MMCO welcome additional  feedback 
or questions  on program requirements  from states, health plans, and other stakeholders.   
The resources listed below are currently  available  from CMS and ICRC: 
  MMCO D-SNP Webpage: https://www.cms.gov/Medicare-Medicaid-
Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/D-SNPs.html.   
 
  Update on State Contracting  with D-SNPs: The Basics and Meeting New Federal 
Requirements  for 2021 (https://www.integratedcareresourcecenter.com/webinar/update-
state-contracting-d-snps-basics-and-meeting-new-federal-requirements-2021)  provides an  CMCS Informational  Bulletin   Page 10 
overview  of state strategies  for contracting  with D-SNPs to improve care coordination 
and Medicare-Medicaid  alignment  for dually  eligible  enrollees.  Special attention  is given 
to new federal D-SNP integration  standards for 2021 contract year, and how states can 
help plans to meet these requirements. 
 
  Promoting  Information  Sharing  by Dual Eligible  Special Needs Plans to Improve Care 
Transitions:  State Options and Considerations 
(https://www.integratedcareresourcecenter.com/resource/promoting-information-sharing-
dual-eligible-special-needs-plans-improve-care-transitions)  examines  the approaches 
used by three states to develop and implement  information-sharing  processes for their D-
SNPs that support care transitions.  The brief includes  examples  of contract language  and 
strategies to encourage plan collaboration  and problem solving  around information 
sharing.  It can help states, D-SNPs, and other stakeholders assess how to meet the new D-
SNP contracting  requirements  and improve the care of dually  eligible  individuals. 
 
  Information  Sharing  to Improve Care Coordination  for High-Risk  Dual Eligible  Special 
Needs Plan Enrollees:  Key Questions for State Implementation   
(https://www.integratedcareresourcecenter.com/resource/information-sharing-improve-
care-coordination-high-risk-dual-eligible-special-needs-plan)  offers key questions  and 
considerations  that states can review as they begin working  with D-SNPs and other 
parties to design and implement  information-sharing  requirements.  This technical 
assistance tool includes  sample contract language.   
 
  Sample Language  for State Medicaid Agency Contracts with Dual Eligible  Special Needs 
Plans (https://www.integratedcareresourcecenter.com/resource/sample-language-state-
medicaid-agency-contracts-dual-eligible-special-needs-plans)  provides sample language 
that states can use in their D-SNP State Medicaid Agency Contracts that is designed to 
comply with CMS requirements.       
More Information 
For more information,  please contact the Medicare-Medicaid  Coordination  Office at 
MMCO_DSNPOperations@cms.hhs.gov.