Response to 30-day comments

ORG. NAME	COMMENT Number	Page Number	Part	Section Number/ Header	Comment	Suggestion (Insert, Delete, or Revise)	CMS RESPONSE (ACCEPT, DENY, CLARIFY, UNDER CONSIDERATION)
Coventry	1			HSD-1, Medicare Provider Breakdown-Nos. 2 8 3 on the table instructions.	The table requires a breakdown of physicians by specialty into physicianswho are 'Direct with MAO' and 'Downstream Arrangement'. We are requesting clarification as to whether the term 'Direct with MAO' would include only single, directly contracted providers (i.e. a one-to-one agreement between the MA0 and physician) or if it would also include a contract between the MA0 and a physician practice where the providers did not sign individual agreements, but are signatories to a group agreement.	Clarification	Clarification: The term direct with MAO can include a contract between the MAO and a physician practice, as well as a single provider.
Coventry	2			HSD-2. Medical Group Affiliation, No. 12 on the table instructions.	The instructions state that "For example, if you have a provider with a direct contract that is affiliated with a 'XYZ' medical group/lPA you must input 'DC' in column number 3 and the name of 'XYZ' medical group/lPA in column 16". There is no 'DC' in the Contract Type instructions under No. 3.	We request that CMS clarify if this means 'D' for direct since that is how it is designated elsewhere on the table.	Clarification/ Revise: the language has been revised instructing the applicant to place a "D" in column 3 of the HSD -table. The "D" represent "Direct" contract.
Coventry	3			HSD-2, Employment Status, No. 13 on the table instructions.	The instructions state to "Indicate whether the provider is an employee of a medical group1lPA or whether a downstream contract is in place for that provider. Insert 'E' if the provider is an employee. Insert 'DC' if a downstream contract is in place for the provider." We are asking for clarification in the event that this is not a mutually exclusive arrangement. There may be instances in which an employee of a medical group is still in a downstream relationship to the MAO. Is this element asking whether the physician is an employee of or has a downstream contract with their medical group IlPA?	Please clarify how the physician should be listed if they are both an employee of the medical group1lPA and delegated with the MAO.	The element pertains to the relationship that supports the MAO application.  If the physician is being brought into the MAO network as an employee of a medical group, then he/she is identified as an employee.  However, if the physician is employed by a medical group on a part time basis, for example, but also has the ability to execute a direct contract with the MAO and does so, then he/she holds the designation of direct contractor for the purpose of the application in question.
Health Partners	4			Overall	1. Will all users have access to the application module or will there be a separate process for requesting security for certain HPMS Users?	no	Clarification: The organization complete an HPMS Userid form for it members. The form will indicate if applicant can create level of access per individual.
Health Partners	5			Overall	2. Will plans have an opportunity to view the application tool on HPMS and provide comments?		No. CMS doesn't allow applicants to comment on our systems module. The automation module is based on the Hardcopy 2009 MA application/
Health Partners	6			Overall	3. Will the application tool have a tracking page so we can see which elements or uploads are missing?		Yes. The module will allow organization to view which sections of the application that is complete or incomplete.
Health Partners	7			Overall	4. There should be sensitivity added to the yes/no answers in attestation boxes.		Organizations can work the regional office if they believe further clarification is need for some of the yes and no questions.
Health Partners	8			Overall	5. If we upload a document on HPMS on 3/1 and need to submit a revised version on 3/9, does that functionality exist?		Yes. However, this functionally will cease if the applicant submits the final submit button prior to March 10, 2008. After the final submit button has been click, organization will have to submit a request to open the gate to their appropriate Plan Manager.
Health Partners	9	10	10.3	Protecting Confidential Information	We used to define specific sections of our applications as confidential and proprietary in the cover letter that accompanied the application. How will this designation be made in an online (HPMS) submission?		This designition will not appear in the online application. Applicants may seek to protect its information from disclosure under the Freedom of Information Act (FOIA) by claiming that FOIA Exemption 4 applies. The Applicant is required to label the information in question “confidential” or “proprietary”, and explain the applicability of the FOIA exemption it is claiming.
Health Partners	10	12	1.2	Administrative Management	Number 10 – replace “executive manager” with “chief executive officer”	Insert	Accept.
Health Partners	11	15	1.5	Compliance Plan	The instructions should specify that the provisions in application will be implemented by 01/01/09 unless specifically noted in individual attestations.	Insert	Revised: Note: All compliance plans must be implemented no later than the effective date of the pending contract. For example: January 1, 2009.
Health Partners	12	18	1.7.3.	Fiscal Soundness	We have a concern about the word “any” financial concerns. This is too broad. Need definitive language.	Revise	Revise: Additionally, applicant will immediately notify CMS if the State identifies any financial concerns that will impact the applicants ability to operate it’s Medicare Advantage contract.
Health Partners	13	19	1.9.2, 3, 4	Provider Contracts & Agreements	N/A for PFFS. Plans use Terms and Conditions. Please provide allowance in attestations.
Health Partners	14	21	1.10.9	Contracts and Administration and Management Services	This statement specifies Part C. Does that mean the other statements apply to both Parts C and D? Please specify.
Health Partners	15	29	1.13.2.A.19	Enrollment, Disenrollment and Eligibility	Spelling error – “disembroils”
Health Partners	16	29	1.13.2.A.21	Same	How is this different than #1, #2 and #4?
Health Partners	17	29	1.13.3.2	Working Aged Membership	Please add limiting language, example “…to the extent we are aware of other coverage.”
Health Partners	18	30	1.13.4	Claims	Please define prompt.
Health Partners	19	30	1.13.4.3	Claims	Please clarify “denial.” Denial of what??
Health Partners	20	30	1.14	Minimum Enrollment	References refer to same section.
Health Partners	21	31	1.15	Communication between MA plan and CMS	Please clarify date action must be completed. We are assuming before January 1st.
Health Partners	22	35	1.2	Medicare Advantage Certification	Typically, the application is completed by staff not authorized to bind the organization. Will CMS separate this piece for officers? Will this be a printed document? Do officers need HPMS access?
Health Partners	23	40	3.1.B.	Access to Services	Is this for network plans only? PFFS plans do not have networks hence, no HSD tables.
Health Partners	24	45	1.2.2	State Licensure	Please remove “some type” language is too broad.
Health Partners	25	50	1.5	HSD	PFFS plans do not have a contracted provider network.
Health Partners		53	D.		Spelling error “are” should be “area”
BCBS of Rhode Island	26			Overall	Disagrees with CMS requiring an applicant to submit an entire applicantion for any new plan in 2009. Believes applicant should not be requried to complete certain section of the application which has been submitted under evergreen contract.	Requsting that organizations be allowed to skip sections of the application that are covered under evergreen contracts.	Clarification given to organization: MAG called BCBS of RI spoke with Kate Sullivan and explained that the Applications submission are at the contract level and not at the PBP level. Explained that the evergreen contract is subject renewal depending upon the approval of the bid, or SAE application. Explain that the automation will allow organization to cut an paste answer if submitting more the one initial application, with the same legality, and product type to reduce of re-entering like information.
Internal Commments-	27			Through out document	The CMS-4124-FC regulation (Compliance Rule) clarified the the term "subcontractor".	Insert the words first tier, downstream, and related entities in parenthesis behind the word "subcontractor).	Accept.
Internal Commments-	28	14	1.5	Compliance Plan	The CMS-4124-FC regulation (Compliance Rule) mandates that we included voluntary self-reporting language concerning fraud, waste and abuse.	Insert: All compliance plans to include voluntary self-reporting of fraud or misconduct.	Accept.
Internal Commments-	29	14	1.5	Compliance Plan	The CMS-4124-FC regulation (Compliance Rule) mandates that we include lanaguge that expand the Part C applicant compliance training to managers, and subcontractors.	Insert: Applicant will implement a compliance plan that designates an employee as the compliance officer and compliance committee accountable to senior management. (Note: This requirement cannot be delegated to a subcontractor (first tier, downstream, and related entities).	Accept.
Internal Commments-	30	21	1. 10	Contracts and Administration and Management Services/ Contract Provisions	The CMS-4124-FC regulation (Compliance Rule) mandates that we included lanaguge expanding the a Part C applicant compliance training to managers, and subcontractors.	Added language that extends CMS audit provision to include medical records and documentation involving transactions related to CMS contract with the MA organization. Also include language authorizing CMS the right to inspect subcontractor’s books, contracts, records, medical records or any documentation related to the Part C contract.	Accept.
Internal Commments-	30		1.17	Appeals	Revise appeals section to reflect Part C Appeals Reconsideration process.	See Medicare Advantage Manual for Appeal provisons.	Accept.