MEDICARE ADVANTAGE
INITIAL APPLICATION
For
PRIVATE FEE-FOR-SERVICE
(PFFS)
PLANS
PFFS applicants seeking to offer Part D Prescription Drug benefits must also timely submit a Medicare Advantage-Prescription Drug Plan Sponsor application to offer Part D Prescription Drug benefits.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services (CMS)
Center for Beneficiary Choices (CBC)
Medicare Advantage Group (MAG)
PUBLIC REPORTING BURDEN: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0935. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
2007
OMB No. 0938-0935 |
CENTER FOR BENEFICIARY CHOICES MEDICARE ADVANTAGE GROUPMEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE (PFFS) APPLICATION |
DOES APPLICANT CURRENTLY OPERATE AN 1876 COST PLAN Yes ___, No ___ PARTIAL COUNTY (422.2(1)(ii) Yes ___, No _____ ARE YOU REQUESTING: Open Access (Non-Network) PFFS Plan _________ or Contracted Network PFFS Plan _______ Number of MA-PD Plans (if applicable)______
Please check all of the following you are requesting with this application: PFFS only______ PFFS MA-PD _____ or PFFS with Employer Group Waiver Plan (EGWP) _____
Product Name of each Medicare Advantage Plan(s): H# (s) if available: |
NAME OF LEGAL ENTITY ORGANIZED AND LICENSED UNDER STATE LAW AS A RISK BEARING-ENTITY:
TRADE NAME (IF DIFFERENT) MAILING ADDRESS:
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CEO OR EXECUTIVE DIRECTOR:
NAME AND TITLE: MAILING ADDRESS: If different than above)
TELEPHONE NUMBER / E-MAIL ADDRESS: FAX NUMBER: ORGANIZATION’S WEBSITE URL : |
APPLICANT CONTACT PERSON: NAME: E-Mail:
TITLE: FAX:
ADDRESS: TELEPHONE NO:
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TAX STATUS For Profit __ Not For Profit __
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I certify that all information and statements made in this application are true, complete and current to the best of my knowledge and belief and are made in good faith. |
Signature CEO/ Executive Director Date
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TABLE OF CONTENTS
The table of contents for the completed application is placed after the cover sheet. Each chapter and subsection title within the Narrative part is marked for automatic generation of the table of contents on this page. That table appears below with page numbering that reflects a "blank" application. The numbers will change when you generate the table again for the completed application. Please follow the directions in the Technical Instructions to generate the table for the Narrative part.
MINIMUM ENROLLMENT WAIVER REQUEST 4
II. MEDICARE CONTRACT INFORMATION 5
III. POLICYMAKING BODY - [422.503] 6
IV. KEY MANAGEMENT STAFF – [422.503] 7
V. MANAGEMENT INFORMATION SYSTEM - [422.503] 8
VII. COMMUNICATION WITH CMS - [422.503] 8
ORGANIZATIONAL AND CONTRACTUAL 10
I. LEGAL ENTITY - [422.4(a) (3)(b) 422.2-422.4] 10
II. STATE AUTHORITY TO OPERATE - [422.6(b)(i) and (2) 422.400, 422.501] 10
III. ORGANIZATIONAL AND FUNCTIONAL CHARTS 10
IV. RISK SHARING (Legal-1 Table) 11
V. CONTRACTS FOR ADMINISTRATIVE/MANAGEMENT SERVICES 422.504 11
VI. PROVIDER CONTRACTS & AGREEMENTS - [422.114, 422.504, 422.520(b)] 11
VIII. COMPLIANCE PLAN - [422.503] 13
I. HEALTH CARE PROVIDERS ‑ Physician Services, Hospital Admitting Privileges – [422.114] 14
II. LOCATIONS OF HEALTH SERVICES PROVIDERS - [422.114] 15
III. MEDICARE HEALTH BENEFITS ‑ [422.101] 15
iV. PROCEDURES FOR BILLING AND PAYMENT 15
V. Health Services Management 16
VI. QUALITY IMPROVEMENTS INITIATIVES 17
II. ENROLLMENT and DISENROLLMENT 18
IV. ENROLLEE RIGHTS AND RESPONSIBILITIES 21
V. MORAL OR RELIGIOUS EXCEPTION - [422.206(b)] 24
VI. MEDICARE MARKETING MATERIAL - [422.80] 24
I. FISCAL SOUNDNESS – [422.502 (f) (1) ] 27
(See Medicare Managed Care Manual Chapters 2)
In accordance with 42 CFR 422.503 and 422.514, an organization must have at least 5,000 enrollees, or 1,500 if non-urban, in order to enter into a MA contract with CMS. However, the regulation allows CMS to grant a waiver of this minimum enrollment up to three years if CMS determines that the organization has the capability to manage a health care delivery system and ability to handle the level of risk required of a MA contractor.
Please check below the Minimum Enrollment Waiver request:
Urban (at least 5,000 enrollees) Non-Urban (1,500 enrollees)
(See Medicare Managed Care Manual Chapter 4)
Complete the following summary description table.
Complete for the requested MA service area. |
Initial Request |
Applicant's Current Enrollment as of (date):__________ Group |
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Non-Group |
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Medicaid |
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Medicare – Cost plan |
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Medicare Other product lines |
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Total Enrollment |
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Date when the Organization's operations began or are proposed to begin |
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Briefly describe the organization in terms of its history and its present operations. Cite significant aspects of its current financial, marketing, general management, and health services delivery activities. (Do not include information requested in the Legal Entity section.) Please include the following:
1. Summary of recent financial performance including the date of achievement of breakeven* and current operating experience.
The extent of the current Medicare population served by the applicant, if any, and the maximum number of Medicare beneficiaries that could be served as a Medicare Advantage PFFS Plan.
Include information about other Medicare contracts held by the MAO, (i.e., 1876, fee for service, PPO, etc.), unless described in the Legal Entity Section.
Please complete and submit the appropriate CMS forms located at http://www.cms.hhs.gov/healthplans/systems/cmsaccess.asp or contact Don Freeberger at 410/786-4586. Specifically, the following refers to the location of the individual forms:
The Medicare Application for Access to CMS Computer Systems is located at http://www.cms.hhs.gov/mdcn/access.pdf or contact Don Freeberger at 410/786-4586 (for HPMS access and, if needed, additional system access requests). Sign pages as indicated.
Note: Submit a separate HPMS request. Submit requests for access to other systems on a separate form. HPMS access is needed in the early stages of the application process to enable the applicant to input application information into the HPMS application module. Combining the HPMS request with other system access requests will delay the HPMS access approval (access to other systems will be needed after application approval). Place the signed forms in the Documents Section. Include the completed forms in both the electronic and hard copies of the application.
The Payment Information form is located at http://www.cms.hhs.gov/MedicareAdvantageApps/Downloads/pmtform.pdf or contact Yvonne Rice 410-786-7626. The document contains organization, financial institution information, and Medicare contractor data. Sign pages as indicated. The completed form needs to be fax to Yvonne Rice at (410) 786-0322.
Due to the implementation of the IACS system, the Plan Authorization form located at: http://www.cms.hhs.gov/healthplans/systems/planauthfrm.pdf is no longer required.
List the members of the organization's policymaking body (name, position, address, telephone number, occupation, term of office and term expiration date). Indicate whether any of the member(s) are employees of the MA organization.
If the applicant is a line of business versus a legal entity, does the Board of Directors of the corporation serve as the policy making body of the organization? If not, describe the policymaking body and its relationship to the corporate Board.
Does the State regulate the composition of the policymaking body? If yes, in what way?
Indicate below the ways in which the policymaking body carries out its responsibilities:
What is the requirement for meeting frequency?
How many times has this body met in the last 12 months?
What is the required number of members of this body?
Are there term limits for the Board members?
What are the provisions for filling vacancies?
What are the quorum requirements?
Is the MA organization's management decisions ratified by the full Board?
How often is the Chief Executive Officer's (CEO) performance formally evaluated?
Does this body have authority to appoint and remove the CEO?
List any policymaking committees, the chairperson and members of each committee. Provide organizational chart(s) showing clear lines of authority, responsibility, and delegation(s) of authority.
Describe the communication within the organization to assure coordination among its physicians, board, and between the Medical Director and key management personnel.
A. Indicate the individuals responsible for the key management functions.
Staff Function |
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Employed By |
CEO/President |
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Medical Director |
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Utilization Mgmt. |
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Utilization Management |
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CFO |
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Marketing |
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Gov’t Relations |
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Management Information Systems |
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Compliance/ Officer |
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Medicare Sales |
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Quality Director |
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B. In the Documents Section, provide brief position descriptions and resumes for the individuals listed above.
C. Provide an organizational chart showing the relationships of the various departments, including the names of the managers or directors. Place the chart at the end of this chapter.
A. Describe the use of the MIS for day-to-day management of the key plan functions as they apply to Medicare as well as long-term planning. Provide a list of key reports, which include a brief description of each and indicates their distribution. Have MIS reports available on-site for evaluation by CMS staff. Indicate whether data can be collected on an individual patient basis or in aggregate.
Explain how the MA organization meets or will meet the Health Insurance Portability and Accountability Act (HIPPA) for electronic transactions.[45 CFR 160, 162, 164]
Describe the organizations MIS capabilities to track and update fee for service reimbursement and payments.
For your expected Medicare enrollment area, clearly describe the requested service area in terms of geographic subdivisions such as counties, cities or townships.
Provide a detailed map (with a scale) of the complete service area clearly showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. Show location of the organization's ambulatory and hospital providers that serve Medicare members. Show on map the mean travel time from six points on the service area boundary to the nearest primary care provider and hospital site. Place the map(s) in the Documents Section.
If requesting more than one benefit plan and the service areas or delivery systems are different, show on the map (or maps) the geographic boundaries and the providers, as described above, and referenced by each MA plan.
If less than full counties are requested, provide justification for the partial counties request. If the area is not a full county, zip codes must be annotated. (Manual Chapter 4)
Describe the applicant's ability to communicate with CMS electronically.
END OF CHAPTER DOCUMENTATION
1. Organizational Chart of relationships of various departments
(See Medicare Managed Care Manual Chapter 11)
Provide information regarding how the applicant is organized under state law. If the applicant does business as (d.b.a.) a name or names different from the name shown on its Articles of Incorporation, provide such name(s) and include a copy of State approval for the d.b.a.(s) in the Documents Section. Provide the name the plan will use to market its Medicare product.
Include in the Documents Section a copy of any articles of incorporation, bylaws and other legal entity documentation. If applicable, provide the Partnership Agreement in the Documents Section.
Describe any changes in the basic organizational structure since Federal approval, such as any changes in the corporate charter or the bylaws. Provide appropriate documentation as applicable. Place all documentation in the Documents Section.
Use the State License table to give information about the jurisdictions in which the organization anticipates Medicare enrollment. Indicate on the table whether the applicant holds a state license, and, if so, the type of license. Also mention whether the state regulates Medicare activities. Give the amount of any state restricted reserve that the state requires for the event of insolvency. Also, list names, addresses, and telephone numbers of appropriate state regulatory officials who have authority over the organization (Refer to Medicare Application Guidelines for additional information for this section).
B. Complete the table cert.doc and place on a disk and place the hard copy in the Documents Section.
C. The applicant must include a completed State Certification form to document that it is licensed under State law or otherwise authorized to operate as a risk bearing entity that may offer health benefits in the service area for which it is requesting a MA Contract. [This form is a separate file cert.doc; place a hard copy in the Documents Section.]
Provide the following organizational and functional charts at the end of this chapter:
1. The MA organizational chart as the organization is licensed and organized under State law as a risk-bearing entity.
2. If the MA organization is a line of business of a corporation, describe and chart the relationship and show the line of business in relation to the corporation.
Show the relationship of the entity that will hold the MA Medicare contract to any parent or subsidiary organization(s).
Contractual Relationships: If applicable, indicate current contractual relationships between the entity that will hold the MA Medicare contract and any administrative, management, and/or marketing service entities.
Legal-1 Table is a summary of insurance or other arrangements for major types of loss and liability. Complete the table to indicate the types of arrangements in effect, or to be in effect, for the proposed area when approved. [This table is a separate file; legal‑1.doc Place a hard copy in the Documents Section.] [422.503]
Describe the MA organization's relationships with related entities, contractors and sub-contractors for the provision of health and/or administrative services specific to the Medicare product.
B. If using a contracted network describe each of the specific functions (health delivery and/or administrative) that are now or will be delegated to medical groups, IPAs, or other intermediate entities. Describe how the MA organization will remain accountable for any functions or responsibilities that are delegated to other entities. Describe how the MA organization oversees, and formally evaluates delegated functions.
C. Include a copy of each administrative service contract and/or delegation agreement in the Documents Section of the application.
D. Complete the administrative/management delegated contracting matrix (matrixadm.doc) for each delegated entity and include it in the Documents Section of the application.
MAO should determine whether it will offer a Network or Non-network model PFFS plan. The MAO should also determine if it is paying providers for any category of service at the Original Medicare allowable payment rates under Medicare Part A or Part B. Please check one of the responses below and follow instructions for each response
( ) YES MAO will be a Non-Network model PFFS product. Do not complete Section VI. Instead, describe the ‘deeming process’ 422.216 (f) and how providers will be paid. Include terms and conditions of payment.
( ) NO MAO will be a network model PFFS product. Identify and complete the remainder of Section VI for those categories of service for which the applicant will be paying less than the Medicare allowable payment rates for those categories of service or a combination of the two.
Note: For purposes of simplicity in completing this application, the term "provider" means physicians, inpatient institutions and other ancillary practitioners. This definition departs from other Medicare definitions of "providers" (hospitals and other inpatient institutions, plus home health services) and "suppliers" (DME or other practitioners and other non-providers).
There should be full documentation of arrangements for health services in the requested service area(s) at the time that the application is submitted. Executed written agreements are considered evidence of an operational health delivery network, which is able to provide access and availability to health services for Medicare enrollees. These arrangements are typically provider contracts, but may also include employment contracts and letters of agreement. Executed written agreements with providers should be submitted at the time the application is submitted to CMS. CMS will accept any legally binding written arrangements. CMS does not accept letters of intent.
NOTE: For this entire section, applicants must demonstrate that all contractual provisions extend to the level of provider actually rendering the service to Medicare beneficiaries and that all levels of contracts and/or agreements meet the CMS requirements. If subcontracts do not mention which insuring organization members will be served, explain how the contracted hospital, IPA, etc., advised its subcontractors about which insuring organizations are covered by subcontractor, e.g., which MA organization memberships will be served. [422.505(i)(3)]. All signature pages must be identifiable and if the provider cannot be identified by the signature page, then the first page of the contract and/or agreement along with signature page should be sent.
Complete "Provider Arrangements" Table - For each proposed service area or distinct delivery system(s) applicant should provide the provider contracts and/or agreements. Contracts and/or agreements should be executed at the time the application is submitted to CMS. [This table is a separate file legal‑2.xls; place a hard copy in the Documents Section. Instructions for this table are in the Guidelines.]
Provide a sample copy of each category of provider contract(s) and/or agreement(s) between the applicant and its primary health care contractors (i.e., direct contract with physicians, medical group, IPA, PHO, hospitals, skilled nursing facilities, etc.) Place in the Documents Section.
Provide the signature pages and an alphabetical listing of contracted providers for each of the major provider(s) from actual contract(s) and /or agreement(s) with these provider entities (i.e., IPAs, medical groups, PHOs or similar entities and hospitals); place in the Documents Section.
Other than Government actions, addressed in paragraph C below, give a brief explanation of the status of each current and past legal action, for the past three years, if applicable, against the applicant.
B. Applicant and its affiliated companies, subsidiaries or subcontractors, subcontractor staff, any member of its board of directors, any key management or executive staff, or any major shareholder (of 5 percent or more) agree that they are bound by 42 CFR Part 76 and attest that they are not excluded by the Department of Health and Human Services Office of the Inspector General or by the General Services Administration.
C. List any past or pending, if known, investigations, legal actions, or matters subject to arbitration brought involving the Applicant (and Applicant's parent firm if applicable) and its subcontractors, including any key management or executive staff, or any major shareholders (5 percent or more), by a government agency (state or federal) over the past three years on matters relating to payments from governmental entities, both federal and state, for healthcare and/or prescription drug services. Provide a brief explanation of each action, including the following:
1. legal names of the parties;
2. circumstances;
3. status (pending or closed); and
4. if closed, provide the details concerning resolution and any monetary payments, or settlement agreements or corporate integrity agreement.
D. Applicant organization will be required to provide financial and organizational conflict of interest reports to CMS, pursuant to instructions to be issued by CMS.
Describe the organization's internal compliance plan. Submit a copy of the MA organization's compliance plan by placing in the Documents Section.
Describe the reporting relationship of the MA compliance officer to the organization's senior management. Describe how the compliance officer and compliance committee is accountable to senior management. List all members of the compliance committee and their positions within the organization.
1. Organizational and Functional chart of the applicant.
2. Organizational Chart between Corporation and MA organization
3. Compliance Plan and Compliance Program
4. Chart of Contractual Relationship with other entities
5. Terms and Conditions of Payment for Non Network Model PFFS plans
(See Medicare Managed Care Manual Chapters 4, 5, 6, and 7)
Determine whether an applicant is a Network or Non-network model PFFS plan. The answer to the following question will determine network or non-network: Is the applicant paying providers, for any category of service, the Original Medicare allowable payment rates under Medicare Part A or Part B (Check one response and follow instructions for each response)?
( ) YES – This is a Non-Network model PFFS plan. Do not complete Sections II and III. Instead, describe the ‘deeming process’ (422.216 (f)) and how providers will be paid. Include a copy of the terms and conditions of payment.
( ) NO – This is a network model PFFS plan. Identify and complete for those categories of service for which the applicant will be paying less than the Medicare allowable payment rates Sections I, II and III.
If the applicant pays providers less than the Medicare allowable payment rates:
A. Describe the health services delivery system through which the organization will furnish covered Medicare services.
B. Complete the tables’ matrix1.doc and place a hard copy in the Documents Section.
C. Complete HSD-1 Table, County Summary of Providers by Specialty. [Complete this table in its file and place a hard copy in the Documents Section.]
D. Please address whether the MA organization will use the same delivery systems of providers for each requested MA plan. If not, clearly delineate variations in the networks.
Explain how the MA organization will ensure that the number and type of providers will be sufficient to meet the needs of the projected enrollment and to cover all MA benefit plans. For example, state how the MA organization will identify shortages in the physicians' specialties or in-patient beds in hospitals or skilled nursing facilities. If the maintenance of a network has been delegated or subcontracted, explain how the applicant will oversee the adequacy of the network.
Will the MA organization use the same delivery systems for the new service area? If so, how does the MA organization assure sufficient providers for projected enrollment? If not, how will services be rendered in the new area?
Complete HSD-2 Table, Provider List – List of Physicians and other Practitioners by County. Submit Microsoft electronic Excel spreadsheet format (electronic copy) only, not in hard copy. [Complete this table in its file on the disk.]
Complete HSD-2A Table, PCP/Specialist Contract Signature Page Index [Complete this table in its file HSD.xls; place a hard copy in the Documents Section.]
A. Complete HSD-3 Table, Arrangements for Medicare Required Services by County. [Complete this table in its file HSD.xls; place a hard copy in the Documents Section.]
Complete HSD–3A Table, Ancillary/Hospital Contract Signature Page Index
Complete this table in its file HSD.xls; place a hard copy in the Documents Section.]
B. Complete HSD-4 Table, Arrangements for Mandatory Supplemental Benefits by County. [Complete this table in its file HSD.xls; place a hard copy in the Documents Section.]
C. Complete HSD-5 Table, Signature Authority Grid [Complete this table in its file HSD.xls; place a hard copy in the Documents Section]
D. Describe how the MA organization will provide for or arrange for all the health care services (that are covered under Part A and Part B of Medicare) for their enrollees. [422.112]
iV. PROCEDURES FOR BILLING AND PAYMENT (Reimbursement Grid)
Describe the billing and payment process for all categories of Medicare Part A and Medicare Part B services and any additional services offered. Please include:
Who will bill the plan and to whom will the plan make payment (e.g., the enrollee and/or the provider)?
Procedures should also address when the provider bills the plan directly versus when members will be liable to pay providers, before being reimbursed by the plan.
Provide a copy of the applicant’s Reimbursement \Grid in the documents section.
Describe Provider Education Strategy for all provider types.
Describe the mechanism by which the plan will notify CMS of violations of the limits on charges to plan enrollees by non-contracting or deemed providers.
Describe the process by which the plan will make available the terms and conditions of plan payment to all providers in a category of service. Provide a copy of the terms and conditions for review by CMS in the documents section.
Describe the mechanism the plan will use to enforce the limits on charges by contract providers (including deemed contractors) to plan enrollees.
Describe any preauthorization procedures (if applicable) or other requirements for coverage that the plan proposes.
Describe the applicant’s provider dispute resolution process.
(Areas of this section are applicable to both network and non network PFFS model unless otherwise noted)
A. Service Management
1. How will the MA organization use CMS’s national coverage decisions and written decision of carriers and intermediaries (LMRP) in the geographic area in which services are covered under the MA plan? [422.101(b)]
2. Describe and provide policies for ensuring that health services are provided in a culturally competent manner to enrollees of different backgrounds.
Service Authorization
Describe the MA organizations written policies and procedures, reflecting current standards of medical practice, for referral authorizations and processing requests for initial authorization of services, or requests for continuation of services.
C. Practice Guidelines
1. Describe how the MA organization ensures compliance with Federal requirements prohibiting employment or contracts with individuals excluded from participation under Medicare or Medicaid. [422.204]
2. Describe procedures, if any, for monitoring utilization, controlling costs and achieving utilization goals for Medicare members for the following:
In-plan and out-of-plan physician services
Laboratory services
X-ray services
Hospital services, including admitting practices and length of stay
Out-of-area hospital services
The applicant's utilization review protocol should be (1) based on current standards of medical practice and (2) should incorporate mechanisms to detect both under- and over- utilization of services. Provide the MA organizations written protocols for utilization review in the Documents Section. [422.152(e)(3)]
D. Enrollee Health Records and Confidentiality – [422.118]
How does the MA organization ensure appropriate and confidential exchange of information among providers?
What are the policies and procedures for sharing enrollee information with any organization with which the enrollee may subsequently enroll?
How does the MA organization assure that enrollees will have timely access to records and information that pertain to them?
Describe the organizations record keeping system through which pertinent information relating to health care of enrollees is accumulated and is readily available to appropriate professionals.
Provide a copy of the tool for conducting an initial assessment of each enrollee’s health care needs. Place this in the Documents Section.
Encounter Data – [422.257]
Describe how the MA organization meets (or will meet) CMS requirements on the electronic submission of encounter data regarding the following:
Inpatient hospital care data for all discharges?
Physician, outpatient hospital, skilled nursing facility and home health agency data and other data deemed necessary by CMS.
Describe any changes that are specific to the requested area for Sections II through III.
PFFS Organizations are exempted from the majority of QI requirements, however, they must meet the following requirements:
Maintain health information systems
Ensure information from providers is reliable and complete
Make all collected information available to CMS
Conduct quality internal reviews
Take corrective action for all problems that come to the organization’s attention
Describe how the organization will meet the above quality improvement initiatives.
(See Medicare Managed Care Manual Chapters, the Medicare Marketing Guidelines).
Marketing strategy – [422.62, 422.64, 422.80(e), 422.100(g)] -- Describe the applicant's Medicare marketing strategy, including:
Overall marketing approach in the marketplace including communication materials and how materials will be developed and used to market the Medicare product
Sales approach and channels that will be used to enroll (e.g. internet, advertising and promotion programs)
Intent to follow Medicare Marketing guidelines
Plans for community education\outreach and public relations
Systems for managing inquiries and servicing members
Marketing staff (include, if applicable, any information on state jurisdiction over required staff licensure, certification, registration, and/or compensation)
Marketing budget
Allocation of resources and efforts to accommodate and market to disabled and socially disadvantaged persons
Marketing representative oversight and training on CMS Medicare Marketing guidelines
All open enrollment periods for each MA plan, including the initial coverage election period; the mandatory annual election period; and any special election periods
Standard and fast track appeal notices
Provide a general narrative describing the compensation and bonus structures in place for sales representatives.
Submit policies and procedures for informing sales staff and members regarding changes in provider and pharmacy network.
By product line, describe your enrollment history for the last 3 years.
B. Enrollment and Disenrollment Processes:
Describe how the applicant will enroll Medicare beneficiaries in accordance with CMS requirements. Include the date the MA organization expects to begin enrolling Medicare members.
Describe the MA organization’s process for receiving and processing enrollments and disenrollments, including beneficiary notification. Include a flow chart that shows each stage of the process for your MA organization, including the responsible entity.
Does the MA organization currently offer a Medicare “wrap around” or supplement? If so, how will the MA organization ensure that there is no health screening of members transferring from a wrap around product to Medicare Advantage product?
Describe the systems, policies and procedures for identifying and reporting Medicare working aged enrollees.
Describe your process for receiving and acting upon membership notifications from CMS.
Retroactive payment adjustments
Note: PFFS plans must demonstrate compliance with 422.114 - Access to services under an MA PFFS plan. In non-network PFFS models, the access requirement is met, when a PFFS plan chooses to pay a particular category of health care providers’ payment rates that are not less than the rates that apply under original Medicare for the provider in question. To demonstrate the ability to pay claims on a Fee-For-Service (FFS) basis, all PFFS applicants submit a reimbursement grid for approval by CMS and must validate a claims system that pays FFS rates accurately and on a timely basis.
Reimbursement Grid
All PFFS applicants must submit an electronic and hard copy of the Reimbursement Grid to CMS for approval. Applicants must provide in the Documents Section a grid that outlines how the applicant will be paying each category of health care provider for Medicare benefits. A link to the CMS MA payment document is:
http://www.cms.hhs.gov/healthplans/rates/out-of-network/default.asp or contact Mervyn John at 410/786-1141.
B. Claims System - Validation
The applicant can validate the claims systems in the following ways:
1. Maintain a current claims system that has been previously tested by CMS and has demonstrated the ability to pay Medicare FFS payments (for example, using a third party claims administrator that CMS has tested previously); or
2. Utilize a claims system that has been CMS approved for a PFFS product; or
3. Validate the applicant’s claims system – Provide in the Documents section reports and/or narrative that clearly substantiates the process used by the applicant to test the claims system that will be paying PFFS claims. This documentation must demonstrate the ability to accurately pay providers of all Medicare services an amount not less than the amount the providers would receive under Original Medicare. In addition, the PFFS applicant must agree to:
a. Sign an Attestation to the PFFS Contract indicating the MA organization has in place the necessary operational claims systems, staffing, processes, functions etc. to properly institute the Reimbursement Grid and pay all providers of Medicare services an amount not less than Original Medicare; (See copy at the end of this chapter) and
b. Upon request the applicant will submit complete and thorough Provider Dispute Resolution Policies and Procedures (P&Ps) with the application to address any written or verbal provider dispute/complaints, particularly regarding the amount reimbursed. This P&P must be extremely clear in all provider materials. The applicant must submit how it is integrated into all staff training – particularly in Provider Relations, Customer Service and in Appeals/Grievances; and
c. Upon request the applicant will submit a biweekly report, to the CMS Regional Office plan manager, data which outlines all provider complaints (verbal and written), particularly where providers or beneficiaries question the amount paid for six months following the receipt of the first claim. This report will outline the investigation and the resolution including the completion a CMS designed worksheet; and
d. Upon request the applicant will submit a biweekly report to the CMS Regional Office plan manager, data which outlines all beneficiary appeals and/or complaints (verbal and written) related to claims for the six months following the receipt of the first claim. This report will outline the investigation and the resolution including the completion a CMS designed worksheet.
NOTE: Should the data indicate that the MA organization offering the PFFS plan is not meeting the access requirements as outlined above, CMS may institute a Claims Payment test, a Corrective Action Plan requiring the MAO to come into compliance and/or move to the initiation of Enforcement Actions as provided in 422.752.
All PFFS applicants must answer the following sections regardless of which option is chosen for Validation of Meeting Access Standards.
C. Describe the claims processing workflow and who is responsible for each stage of the process for the MA organization. Include a flow chart and all Policies and Procedures of this process and place at the end of this chapter.
D. Provide a list of all claim denial codes and reasons for denial used in the Medicare contract (do not include commercial).
E. Describe the MA organization's ability to document interest payment requirements on claims, which are not paid on a timely manner.
Answers to the following questions are needed if the applicant is paying providers payment rates that are equal to or greater than the rates that apply under Original Medicare (Non-network PFFS plan):
1. Describe in detail the system in place that allows the MAO to obtain payment information for any Medicare approved provider throughout the nation.
2. Provide an electronic and hard copy of the PFFS plan’s Terms and Conditions in the Documents Section that will be made available to potential providers.
3. Describe how providers will be able to access the terms and conditions.
4. Will providers be allowed to balance bill the beneficiary? If balance billing is allowed, describe the organizational requirements and processes. Include all communications to beneficiaries and providers. Provide Policies and Procedures and how the plan will inform the beneficiaries and providers of this requirement. Provide the Policies and Procedures in the Documents Section.
5. How will the Plan monitor the amount collected by non-contracted providers to ensure that these amounts do not exceed the amounts permitted to be collected under law?
6. How will the Plan provide to enrollees an appropriate explanation of benefits for each claim filed by the enrollee or provider? The explanation must include a clear statement of the enrollee’s liability for deductibles, coinsurance, co-payment and balance billing. Describe and attach a copy.
7. Describe the provider payment appeal process. Provide a flow chart, Policies and Procedures, education materials, etc., of this process.
(Areas of this section may be applicable to both network and non network PFFS model)
Explain the MA organization's member complaints and grievance procedures and how this will be available to Medicare enrollees. Provide a flow chart of the MA organization's Medicare enrollee complaint and grievance procedures. [422.564]
Explain
how the MA organization will handle Medicare reconsideration and
appeals procedures, including expedited determinations and expedited
reconsideration. Provide a flow chart of the MA organization's
Medicare reconsideration and appeals procedures (including expedited
determinations). Describe how the organization will respond to
reversals of Medicare reconsideration determinations by the
Independent Review Entity. [422.566, 422.618(b)]
Provide the MA organization's policies and explain projected procedures for implementing those policies with respect to enrollee rights. This includes detailing mechanisms for communicating policies to enrollees at the time of enrollment, and thereafter on a yearly basis; how the organization will ensure its compliance with Federal and state laws affecting the rights of Medicare enrollees.
[422.112(a)(8), 422.112(a)(8)(I), 422.112. (a) (10),(I), 422.100(G)].
Describe how the applicant will ensure the following:
The MA organization will handle Medicare enrollees’ privacy with regards to each enrollee being treated with respect and dignity including the protection of any information that identifies a particular enrollee.
The MA organization will ensure the confidentiality of health and medical records of other information about enrollees. [422.118(a)]
The MA organization will ensure that enrollees are not discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, sex, age, and mental or physical disability. [422.110(a)]
The MA organization will ensure that all services both clinical and non-clinical are accessible to all including those with limited English proficiency or reading skills, and those with diverse cultural and ethnic backgrounds. [422.112(a)(9)]
The MA organization will ensure that enrollees participate in decision-making regarding the enrollee's health care and if unable to do so, the MA organization provides for the enrollees representative to facilitate care or treatment decision when the enrollee is unable to do so. [422.206(b), 422.128(a), 422.128(b)]
The MA organization will ensure that the enrollee will receive information on available treatment options (including the option of no treatment) or alternative sources of care. The MA organization must ensure that information provided by health care professionals regarding treatment options are in a language that the enrollee understands. [422.206(a)(1)i), 422.206(a)(2)]
The MA organization will follow to ensure enrollees will have access to one's medical records in accordance with applicable Federal and State laws. [422.118(a), 422.118(d)]
The MA organization will ensure prompt resolution of issues raised by the enrollee, including complaints or grievances and issues relating to authorization, coverage or payment for services. [422.118(d)]
Describe how the MA organization will ensure that the following enrollee information is received at the time of enrollment and at least annually thereafter, a written statement including information that is readable and easily understood for each area, refer to regulations at: [422.111 (a)(1-3), (422.111(b)(1)-(10))]
The MA organization will ensure that enrollees are provided information on the MA plan's service area and any enrollment of continuation area(s), if applicable. [422.111(b)(1)]
The MA organization will ensure that all enrollee information on benefits and services including mandatory and supplemental benefits will be provided in an appropriate manner. [422.111(b)(2), 422.111(b)(6)]
The MA organization will ensure that enrollees have information on the number, mix and distribution of providers including out-of-network coverage, point-of-service etc. [422.111(b)(3)]
The MA organization will ensure that enrollees are provided information on emergency coverage, including, the appropriate use of emergency services, and policies and procedures. [422.111(b)(5)(I-IV)]
The MA organization will ensure the right to access emergency health care services is consistent with the determination of the need for services by a prudent layperson. [422.113]
The MA organization will ensure that enrollees are informed of prior authorizations and review rules. [422.111(b)(7)]
The MA organization will ensure that all enrollee’s rights have been provided on the grievance and appeals procedures. [422.111(b)(8)]
The MA organization will provide for enrollees’ disenrollment rights and responsibilities. Explain how the MA organization will provide to the enrollee upon request any disclosures. [422.111(b)(10), 422.111(c)(1-5)]
E. For each of the following describe the MA organization's system for resolution of enrollee issues which are raised by enrollees, including complaints and grievances, issues related to authorization of, coverage of, or payment of services; and issues related to discontinuation of service [Note: references to an enrollee in these standards include reference to an enrollee's representative]. [422.564(a)(2), 422.152(c), 422.562(a)(I), 422.562(a)(ii)]
Explain how the applicant will ensure the following:
The MA organization will ensure that it follows its own written procedures for processing all issues raised by enrollees.
The MA organization will implement procedures (with clearly explained steps and time limits for each step) for the resolutions of a compliant or grievance by enrollees. [422.564(a)(1), 422.564(a)(2), 422.564(b)(1)]
The MA organization will implement procedures, (That clearly explain steps and time limits for each step) for reviewing coverage and payment requests for reconsideration of initial decisions that the MA organization chooses not to provide or pay for a particular service. [422.564(b)(4), 422.564(b)(iii)]
4. The MA organization will monitor the resolution of enrollee issues. How will the MA organization ensure that it maintains, aggregates and analyzes the resolution of enrollee issues? [422.152(f)(1)]
F. Patient self-determination Act - Explain the MA organization's process of providing information regarding advance directives to members at the time of a member's enrollment.
G. Describe how the applicant will comply with the prohibitions against MA organization interference with health professional advice to enrollees regarding enrollees' care and treatment options.
H. Describe the process for assuring the applicant will conduct an initial assessment of each enrollee's health care needs within 90 days of effective date of enrollment [422.112(b)(4)(i) ]
If the MA organization is requesting an exception to covering a particular counseling or referral service due to moral or religious grounds, state the service and explain the reasons for the request.
Definition: 422.80(b)
Marketing materials include any applicable informational materials targeted to Medicare beneficiaries which:
(1) Promotes the MA organization, or any MA plan offered by the MA organization;
(2) Inform Medicare beneficiaries that they may enroll, or remain enrolled in an MA plan offered by the MA organization;
(3) Explain the benefits of enrollment in a MA plan, or rules that apply to enrollees;
(4) Explain how Medicare services are covered under an MA plan; including conditions that apply to such coverage.
Marketing materials listed below do not have to be submitted with the application or approved prior to the contract being awarded. However, before a MA Organization can market or advertise its Medicare products the MAOs must be in compliance with the statutory requirements for approval of marketing materials and election forms as outlined in Section 1851 of the Social Security Act, Section 422.80 of the CFR and Applicable Medicare Managed Care Manual Chapters.
Subscriber agreement/Evidence of coverage
Member handbook
Application form
Disenrollment form
Membership card
Brochures/Advertising materials
Radio/TV scripts
All letters, not limited to the following: denial of enrollment, disenrollment due to non-payment of premiums, move out of service area, working aged survey etc.
Provider Directory
Notice of organization determination for service, claim denial and service denial notices.
Authorization/referral forms
Material prepared by contracting IPAs and Groups
Correspondence relating to grievances/appeals
Notice of discharge and Medicare appeals rights (NODMAR); Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non- Coverage (DENC)
Forms for patient self-determination
Written notice to beneficiaries of termination of a contracted provider.
Notices of a service exception due to moral or religious grounds, if applicable
If applicable, Employer Group marketing material [refer to 422.80(f)]
Summary of benefits
All denial and grievance letters
MEDICARE
1. Reimbursement Grid and Policy and Procedures for quarterly updates to CMS.
2. Substantiation of claims system capabilities to pay claims – Flow chart of claims processing workflow with responsibility outlined
a. Narrative on how the test process was conducted to pay all PFFS claims
b. Provide five actual test claims as examples for each provider type with a results report for each provider type.
c. Describe the plan’s evaluation process (how did the plan determine the amount was accurate to FFS payments), discrepancies noted and corrective actions taken.
d. Policies and Procedures on payment processes for all provider types represented in the Reimbursement Grid. Describe edits used.
e. List of Claim denial codes and reasons
f. List of Public Use Files accessed and loaded into the claims system.
3. Terms and Conditions of Payment for Non Network Model PFFS plans
4. Provider Dispute Resolution Policies and Procedures
5. All Provider education materials
6. Policies and Procedures for Balance Billing
7. Copies of Beneficiary and Provider notifications of payments (Explanation of Benefits and Payment Advice)
8. All Marketing Materials
ON SITE DOCUMENTS
1. Policy and Procedure Manuals for claims processing, appeals, enrollment, provider relations, reimbursement
2. Staffing plans for all operational areas.
3. Provider appeal flowchart
Please provide a copy of your most recent independently certified audited statements. (An MA organization that does not have a state license at the time of this application, or is within it’s first year of operation with no audit, please submit a copy of the financial information that was submitted at the time the State licensure was requested.)
Please submit an attestation signed by the Chairman of the Board, Chief Executive Officer and Chief Financial Officer attesting to the following:
1. The MA Organization will maintain a fiscally sound operation and will notify CMS if it becomes fiscally unsound during the contract period.
2. The MA organization is in compliance with all State requirements and is not under any type of supervision, corrective action plan, or special monitoring by the state regulator. NOTE: If the MA organization cannot attest to this compliance, a written statement of the reasons must be provided.
CERTIFICATION OF CLAIMS PAYMENT SYSTEMS RELATING TO THE MEDCARE ADVANTAGE ORGANIZATION’S ABILITY TO PAY PROVIDER CLAIMS ACCURATELY ON A FEE-FOR-SERVICE BASIS
Pursuant to the contracts(s) between the Centers for Medicare & Medicaid Services (CMS) and (INSERT NAME OF MEDICARE ADVANTAGE ORGANIZATION), hereafter referred to as the Medicare Advantage Organization (MAO), governing the operation of the following Medicare Advantage plans (INSERT PLAN IDENTIFICATION NUMBERS HERE),hereby makes the following certification to CMS. The MAO acknowledges that the information described below is accurate, complete and truthful and that misrepresentations to CMS about the accuracy of such information may result in Federal civil action and/or criminal prosecution.
The MAO has an operational claims payment system that is duly tested, and has the ability to pay providers rates that are not less than rates that apply under original Medicare for the provider in question. For services that currently have no Medicare fee schedules, the MAO will pay providers rates that CMS has approved on the MAO’s reimbursement grid.
_____________________________
(INDICATE TITLE [CEO, CFO, or delegate])
On behalf of
_____________________________________
(INDICATE MA ORGANIZATION)
Note: PFFS plans are not required to offer the Part D drug benefit. MSA plans may not offer the Part D drug benefit.
The Medicare Modernization Act requires that coordinated care plans offer at least one MA plan that includes a Part D prescription drug benefit (an MA-PD) in each county of its service area. To meet this requirement, your organization must timely complete and submit a separate Medicare Advantage Group Prescription Drug Plan application (MA-PD application) in connection with the MA-PD. Failure to file the required MA-PD application will result in a denial of this application and will not be considered an “incomplete” MA application.
The MA-PD application can be found at:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage or you may contact Marla Rothouse at 410/786-8063. Specific instructions to guide MA organizations in applying to qualify to offer a Part D benefit during 2007 are provided in the MA-PD application.
The MA-PD application is an abbreviated version of the application used by stand-alone Prescription Drug Plan (PDPs), as the regulation allows CMS to waive provisions that are duplicative of MA requirements or where a waiver would facilitate the coordination of Part C and Part D benefits. Further, the MA-PD application includes a mechanism for Medicare Advantage organizations to request CMS approval of waivers for specific Part D requirements under the authority of 42 CFR 423.458 (b)(2).
GENERAL INFORMATION
Service Area Maps……………………………………………………………………………….
ORGANIZATIONAL AND CONTRACTUAL
State Certification Form [cert.doc] ……………………………………………………………….
Legal Table 1 [legal-1.xls] ……………………………………………………………………..
Template Contracts/Agreements for Administrative/Management Services……………………
Matrix for Administrative/Management Services [matrixadm.doc] …………………………….
Legal Table 2 – Provider Arrangements [legal-2.xls]…………………………………………..
Template Contracts/Agreements for Direct Provider Contracts...........…………………………
Matrix for Direct Provider Contracts/Agreements [matrix1.doc]………………………………..
Template Contracts for Subcontracts (Medical Groups, IPAs, PHOs, etc.)…..………………....
Matrix for Subcontracted Provider Contracts/Agreements [matrix1.doc]..………………………
HEALTH SERVICES DELIVERY
HSD Table 1 [HSD.xls]………………………………………………………………………
HSD Table 2 [HSD.xls]………………………………………………………………………
HSD Table 2A [HSD.xls]..…………………………………………………………………..
HSD Table 3 [HSD.xls]………………………………………………………………………
HSD Table 3A [HSD.xls]…………………………………………………………………….
HSD Table 4 [HSD.xls]………………………………………………………………………
HSD Table 5 [HSD.xls]………………………………………………………………………
MEDICARE
Marketing materials…………………………………………………………………………
FINANCIAL
Attestation…………………………………………………………………………………………..
For PFFS: Payment Grid and Reimbursement Methodology ……………………………………..
Terms and Conditions …………………………………….…………………………………….
To add the page numbers for the Documents table of contents, place cursor at the end of each line (using the End key) and type in the page number. Do not press ENTER, just place the cursor at the end of the next line for the next page entry.
* Break-even is defined as the point of maximum cumulative deficits followed by two consecutive quarters during which operating revenues exceeded operating expenses. Break-even date shall be the first day of the first quarter.
| File Type | application/msword |
| File Title | Mervyn, |
| Author | GJC4 |
| Last Modified By | CMS |
| File Modified | 2006-03-24 |
| File Created | 2006-03-24 |