MEDICARE ADVANTAGE
MASTER APPLICATION
For all new applicants and existing Medicare Advantage contractors seeking to expand a service area -- CCP, PFFS, MSA, RPPO, & SNP Proposals
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services (CMS)
Center for Beneficiary Choices (CBC)
Medicare Advantage Group (MAG)
Medicare Advantage Coordinated Care Plans (CCPs) must offer Part D prescription drug benefits under at least one Medicare Advantage plan in each county of its service area, and therefore must timely submit a Medicare Advantage-Prescription Drug(MA-PD) application to offer Part D prescription drug benefits as a condition of approval of this application.
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 32 hours per response, including the time to review instructions, search existing data resources, and 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.
PART 1 GENERAL INFORMATION 5
1. Overview 5
2. Types of MA Products and MA Applicants 5
3. Important References 6
4. Technical Support 6
5. Health Plan Management System (HPMS) 7
6. Submit Intent to Apply 7
7. Due date For MA Application 8
8. General MA Application Instructions 8
9. MA Part D (MA-PD) Prescription Drug Benefit Instructions 9
10. Additional Information 9
10.1 Bid Submission and Training 9
10.2 System and Data Transmission Testing 10
10.3 Protecting Confidential Information 10
10.4 Payment Information Form 10
PART 2 INITIAL APPLICATIONS 11
SECTION 1 ALL MA APPLICANTS (CCP, PFFS, RPPO, & MSA) 12
1.1 Experience & Organization History 12
1.2 Administrative Management 12
1.3 State Licensure (For CCP, PFFS, & MSA Applicants Only) 13
1.9 Provider Contracts & Agreements 19
1.10 Contracts for Administrative & Management Services 21
1.12 Quality Improvement Program (CCP & RPPOS ONLY) 24
1.13.2 Enrollment, Disenrollment, and Eligibility 27
1.13.3 Working Aged Membership 29
1.15 Communication between Medicare Advantage Plan and CMS 31
1.20 Medicare Advantage Certification 35
SECTION 2 REGIONAL PREFERRED PROVIDER ORGANIZATION (RPPO) APPLICANTS ONLY 36
SECTION 3 PRIVATE FEE FOR SERVICE (PFFS) APPLICANTS ONLY 40
SECTION 4 MEDICAL SAVINGS ACCOUNTS (MSA) & MSA DEMO APPLICANTS ONLY 43
4.1 General Administration/ Management 44
SECTION 5 MSA DEMONSTRATION APPLICANTS ONLY 46
5.1 MSA Demonstration Addendum 46
PART 3 SERVICE AREA EXPANSION APPLICATIONS 47
SECTION 1 ALL MA APPLICANTS (CCP, RPPO, PFFS, & MSA) 47
1.1 Contract Number in HPMS 47
1.2 State Licensure (CCP, PFFS, & MSA Applicants Only) 47
1.3 Provider Contracts & Agreements 48
1.4 Contracts for Administrative & Management Services 49
1.5 Health Services Delivery (HSD) 51
SECTION 2 SERVICE AREA EXPANSIONS FOR RPPO APPLICANTS ONLY 54
S Error! Bookmark not defined.
PART 4 SOLICITATIONS FOR SPECIAL NEEDS PLAN PROPOSAL PLAN 59
1. GENERAL GUIDANCE ON COMPLETING SNP PROPOSAL 60
2. REQUIREMENTS TO SUBMIT A SNP PROPOSAL 60
4. TEMPLATE FOR COMPLETING SNP PROPOSAL 67
ATTACHMENT G – Dialysis Facilities Table 92
ATTACHMENT H –Transplant Facilities Table 93
ATTACHMENT I – Long Term Care Facilities Table 94
ATTACHMENT J-Pre-enrollment Verification 95
2.1. Form and Table Management 103
2.2 Instructions for CMS Insurance Coverage Table 103
2.3. Instructions for CMS State Certification Form 104
2.4. Instructions for CMS Provider Arrangements by County Table 106
2.5. Instructions for CMS Provider Participation Contracts and/or Agreements Matrix 107
2.5. Instructions for CMS Provider Participation Contracts and/or Agreements Matrix 107
2.6. Instructions for CMS Administrative/Management Delegated Contracting or Arrangement Matrix 108
2.7. General Instructions for CMS HSD Tables 1, 2, 2a, 3, 3a, 4, 5 109
2.7.1 Table: HSD-1: County/Delivery System Summary of Providers by Specialty 110
2.7.2 Table: HSD-2: Provider List - List of Physicians and Other Practitioners by County 112
2.7.3 Table HSD-2a: PCP/Specialist Contract Signature Page Index 114
2.7.4 Table HSD-3: Arrangements for Medicare Required Services by County 115
2.7.5 Table HSD-3a: Ancillary/Hospital Contract Signature Page Index 117
2.7.6 Table HSD-4: Arrangements for Additional and Supplemental Benefits 118
2.8. Table: Essential Hospital Designation Table 121
PART 6 LISTS OF REQUESTED DOCUMENTS 122
PART 7 CMS REGIONAL OFFICES 130
18343535404141414.2 Access to Services 423 Claims Systems & 424.4 Payment Provisions 43SECTION 5 MSA DEMONSTRATION APPLICANTS ONLY 445.1 MSA Demonstration Addendum 44SECTION 1 ALL MA APPLICANTS (CCP, RPPO, PFFS, & MSA) 451.1 Contract Number in HPMS 451.2 State Licensure (CCP, PFFS, & MSA Applicants Only) 451.3 Provider Contracts & Agreements 461.4 Contracts for Administrative & Management Services 471.5 Health Services Delivery (HSD) 491.6 Service Area 51SECTION 2 SERVICE AREA EXPANSIONS FOR RPPO APPLICANTS ONLY 512.1 State licensure RPPO 512.2 Access Standards 522.3 Essential Hospital 54PART 4 SOLICITATIONS FOR PECIAL NEEDS PLAN PROPOSAL PLAN 551. GENERAL GUIDANCE ON COMPLETING SNP PROPOSAL 552. REQUIREMENTS TO SUBMIT A SNP PROPOSAL -- MA AND PART D APPLICATIONS MAY ALSO BE REQUIRED 563. KEY DEFINITIONS 604. TEMPLATE FOR COMPLETING SNP PROPOSAL 62A 82B 83C D 86E 87F 88G – Dialysis91H –Transplant92ATTACHMENT I – Long Term Care Facilities Table 93J-Pre-enrollment Verification 94PART 5 INSTRUCTIONS FOR COMPLETING CMS FORMS PART 5 INSTRUCTIONS FOR COMPLETING CMS FORMS 2.2 Insurance Coverage Table 1002 Insurance Coverage1013Arrangements by County Table 10345Provider Participation Contracts and/Agreements1042.5. Instructions for CMS Administrative/Management Delegated Contracting or Arrangement Matrix 1052.6. Instructions for CMS Administrative/Management Delegated Contracting or Arrangement Matrix 1062.7.1 Table: HSD-1: County/Delivery System Summary of Providers by Specialty 1072.7.2 Table: HSD-2: Provider List - List of Physicians and Other Practitioners by County 1082.7.2 Table: HSD-2: Provider List - List of Physicians and Other Practitioners by County 1102.7.4 Table HSD-3: Arrangements for Medicare Required Services by County 11143Medicare Required Services by County 1132.7.6 HSD-4: Arrangements for Additional and Supplemental Benefits1142.7.6 Table HSD-4: Arrangements for Additional and Supplemental Benefits 1172.8. Table: Essential Hospital Designation Table 118
In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) significantly revised the Medicare + Choice managed care program, now called the Medicare Advantage (MA) program, and added outpatient prescription drugs to Medicare (offered by either stand-alone prescription drug plan sponsors or MA organizations). The MMA changes make managed care more accessible, efficient, and attractive to beneficiaries seeking options to meet their needs. The MA program offers new kinds of plans and health care choices, such as regional preferred provider organization plans (RPPOs), private fee-for-service plans (PFFS), Special Needs Plans (SNPs), and Medical Savings Account plans (MSAs).
The Medicare outpatient prescription drug benefit is a landmark addition to the Medicare program. More people have prescription drug coverage and are saving money on prescription drugs than ever before. Costs to the government for the program are lower than expected, as are premiums for prescription drug plans,
People with Medicare not only have more quality health care choices than in the past but also more information about those choices. The Centers for Medicare & Medicaid Services (CMS) welcome organizations that can add value to these programs, make them more accessible to Medicare beneficiaries and meet all the contracting requirements.
The MA program is comprised of a variety of product types including:
Coordinated Care Plans
Health Maintenance Organizations (HMOs) with/without a Point of Service(POS) benefit
Local Preferred Provider Organizations (LPPOs)
Regional Preferred Provider Organizations (RPPOs)
State Licensed Provider-Sponsored Organizations (PSOs)
Special Needs Plans (SNPs)
Private Fee-for-Service (PFFS) plans
Medical Savings Account plans (including Medical Savings Account Demonstration plans)
Note: For facts sheets on each of these types of product offerings go to http://www.cms.hhs.gov/HealthPlansGenInfo/Downloads/cmsregional.pdf
Qualifying organizations may contract with CMS to offer any of these types of products. To offer one or more of these products an application must be submitted according to the instructions in this application.
The applicant can either be “new”, meaning the applicant is seeking a new MA contract for a type of MA product they do not already offer, or “existing”, meaning the applicant is seeking a service area expansion under an existing contract.
Note: The Medicare Modernization Act requires that CCPs 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, the applicant must timely complete and submit a separate Medicare Advantage Group Prescription Drug Plan application (MA-PD application) in connection with the MA-PD.
Note: PFFS plans have the option to offer the Part D drug benefit. MSA plans can not offer the Part D drug benefit.
Note: All applicants who wish to offer Employer/Union-Only Group Waiver Plan must complete a separate EGWP application in HPMS. There are two types of EGWP applications: MAO “800 Series” EGWP application and Employer/Union Direct Contract PFFS MAO application.
The following are key references about the MA program:
Social Security Act -- 42 USC 1395 et seq. http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
Medicare Regulations--42 CFR Part 422
Medicare Managed Care Manual--http://www.cms.hhs.gov/HealthPlansGenInfo/
Medicare Marketing Guidelines –http://www.cms.hhs.gov/ManagedCareMarketing/
CMS Central and Regional Office staffs are available to provide technical support to all applicants during the application process. Applicants may call Kateisha Martin in the CMS Central Office at (410) 786-4651, or a Regional Office to request assistance. A list of CMS Regional Office contacts can be found in Part 7 of this application.
For general information about this application please send an email to the following email address: [email protected]
CMS also conducts special training sessions and user group calls for new applicants and existing contractors. All applicants are strongly encouraged to participate in these sessions which will be announced via HPMS and/or CMS main website.
A. The HPMS is the primaryprinciple information collection vehicle through which MA organizations will communicate with CMS in support of the application process, bid submission process, ongoing operations of the MA program, and reporting and oversight activities.
B. Applicants are required to enter contact and other information collected in HPMS in order to facilitate the application review process. Applicants are required to provide prompt entry and ongoing updates of data in HPMS. By keeping the information in HPMS current, the applicant facilitates the tracking of its application throughout the review process and ensures that CMS has the most current information for application updates, guidance and other types of correspondence. In the event that an applicant is awarded a contract, this information will also be used for frequent communications during implementation. Therefore, it is important that this information be accurate at all times.
C. HPMS is also the vehicle used to disseminate CMS guidance to MA organizations. The information is then incorporated in the appropriate manuals. It is imperative for MA organizations to independently check HPMS notices and incorporate the guidance as indicated in the notices.
Organizations interested in applying for a Medicare Advantage product must complete a Notice of Intent to apply form by December 5XX, 2007. Upon submitting the completed form to CMS the organization will be assigned a pending contract number (H number) to use throughout the application and subsequent operational processes.
Once the contract number is assigned, the applicant should request a CMS User ID. An application for Access to CMS Computer Systems (for HPMS access) is required and can be found at: http://www.cms.hhs.gov/AccesstoDataApplication/Downloads/Access.pdf . Upon approval of the CMS User ID request, the applicant will receive a CMS User ID(s) and password(s) for HPMS access.
Applications must be submitted by 5:00 P.M.EST, March XX, 2008. CMS will not review applications received after this date and time. Applicants’ access to application fields within HPMS will be blocked after this date and time.
Below is a tentative timeline for the Part C (MA program) application review process:
APPLICATION REVIEW PROCESS |
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Milestone |
December 2007
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New MA organizations: 1. Submit notice of intent to apply to CMS 2. Request HPMS Access (Includes User ID and Password Request) 3. Request CMS Connectivity |
January 2008 |
Final Applications Posted by CMS |
March 2008 |
Applications due
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April 2008 |
Plan Creation module, Plan Benefit Package (PBP) and Bid Pricing Tool (BPT) available on HPMS |
May 2008 |
PBP/BPT Upload Module available on HPMS |
May/June 2008 |
CMS mails Part C (MA program) conditional contract eligibility determination to Applicants, based on review of application. |
June 2008 |
All bids due. |
September 2008 |
CMS completes review and approval of bid data. CMS executes Part C (MA program) contract to organizations who submit an acceptable bid, and otherwise meet CMS requirements. |
November 2008 |
2008 Annual Coordinated Election Period begins for January 1, 2009, effective date for 2009 plans. |
Applicants must complete the 2009 MA application using the HPMS as instructed. CMS will not accept any submission using prior versions of the MA application. All documentation must contain the appropriate CMS issued contract number.
In preparing a response to the prompts throughout this application, the Applicant must mark “Yes” or “No” in sections organized with that format. By responding “Yes”, the Applicant is committing its organization to complying with the relevant requirement as of the date the Medicare contract is signed.
All aspects of the program to which the Applicant replies “Yes” to must be ready for operation by the effective date of the signed contract. CMS may verify an Applicant’s readiness and compliance with Medicare requirements, through on-site visits at the Applicant’s facilities as well as through other program monitoring techniques. Failure to meet the requirements represented in this application and to operate MA plans consistent with the applicable statutes, regulations, and the MA contract, and other CMS guidance could result in the closure of plan marketing and enrollment. If corrections are not made in timely manner, the Applicant will be disqualified from participation in the MA program.
Throughout this application, applicants are asked to provide various documents and/or tables in HPMS. Part 5 of this application lays out instructions for completing some of the requested CMS forms and tables. Part 6 of this application provides a list of all requested documents and/or tables. The list includes the name, the reference point within the application, the format to use when submitting the application, and a file naming nomenclature.
The legal entity that submits this application must be the same entity with which CMS enters into a MA contract.
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 applicants to request CMS approval of waivers for specific Part D requirements under the authority of 42 CFR 423.458 (b)(2). The MA-PD application can be found at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage or the applicant may contact Marla Rothouse at 410-786-8063. Specific instructions to guide MA applicants in applying to qualify to offer a Part D benefit during 2009 are provided in the MA-PD application and must be followed.
Note: Failure to file the required MA-PD application will be considered an “incomplete” MA application and could result in a denial of this application.
Failure to submit application supporting documentation consistent with these instructions may delay the review by CMS and may result in the applicant receiving a Notice of Intent to Deny.
10.1 Bid Submission and Training
On or before the first Monday of June of every year, MA organizations must submit a bid, comprised of the proper benefits and pricing for each MA plan for the upcoming year based on its determination of expected revenue needs. Each bid will have 3 components, original Medicare benefits (A/B), prescription drugs under Part D (if offered under the plan), and supplemental benefits. Bids must also reflect the amount of enrollee cost sharing. CMS will review bids and request additional information if needed. MA Organizations must submit the benefit plan or plans it intends to offer under the bids submitted. No bid submission is needed at the time the application is submitted. Further instructions and time frames for bid submissions are provided at http://www.cms.hhs.gov/MedicareAdvantageApps.
In order to prepare plan bids, Applicants will use HPMS to define its plan structures and associated plan service areas and then download the Plan Benefit Package (PBP) and Bid Pricing Tool (BPT) software. For each plan being offered, Applicants will use the PBP software to describe the detailed structure of its MA benefit and the BPT software to define its bid pricing information.
Once the PBP and BPT software have been completed for each plan being offered, Applicants will upload their bids to HPMS. Applicants will be able to submit bid uploads to HPMS on its PBP or BPT one or more times between early May 2008 and the CY 2009 bid deadline, the first Monday in June 2008. CMS will use the last successful upload received for a plan as the official bid submission.
CMS will provide technical instructions and guidance upon release of the HPMS bid functionality as well as the PBP and BPT software. In addition, systems training will be available at the Bid Training in April 2008.
10.2 System and Data Transmission Testing
All MA organizations must submit information about its membership to CMS electronically and have the capability to download files or receive electronic information directly. Prior to the approval of a contract, MA organizations must contact the MMA Help Desk at 1-800-927-8069 for specific guidance on establishing connectivity and the electronic submission of files. Instructions are also on the MMA Help Desk web page, www.cms.hhs.gov/mmahelp, in the Plan Reference Guide for CMS Part C/D systems link. The MMA Help Desk is the primary contact for all issues related to the physical submission of transaction files to CMS.
10.3 Protecting Confidential Information
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. When there is a request for information that is designated by the Applicant as confidential or that could reasonably be considered exempt under Exemption 4, CMS is required by its FOIA regulation at 45 CFR §5.65(d) and by Executive Order 12,600 to give the submitter notice before the information is disclosed. To decide whether the Applicant’s information is protected by Exemption 4, CMS must determine whether the Applicant has shown that— (1) disclosure of the information might impair the government's ability to obtain necessary information in the future; (2) disclosure of the information would cause substantial harm to the competitive position of the submitter; or (3) disclosure would impair other government interests, such as program effectiveness and compliance; or (4) disclosure would impair other private interests, such as an interest in controlling availability of intrinsically valuable records, which are sold in the market. Consistent with our approach under other Medicare programs, CMS would not release information that would be considered proprietary in nature.
Please complete the Payment Information form that is located at:
http://www.cms.hhs.gov/MedicareAdvantageApps/Downloads/pmtform.pdf
The document contains financial institution information and Medicare contractor data.
If the applicant has questions about this form please contact Yvonne Rice at 410-786-7626. The completed form needs to be faxed to Yvonne Rice at (410) 786-0322.
The MA application must be completed using the HPMS except as indicated throughout. Section 1 of the application, must be completed by all applicants applying for a new contract type (e.g. CCP, PFFS, MSA, RPPO or SNP) for which the applicant does not already have a Medicare contract. If the applicant is seeking a service area expansion or a new SNP type under an existing Medicare contract, then an initial application should not be completed; rather a Service Area Expansion Application must be completed. Applicants applying for a Regional PPO, PFFS, MSA, or Special Needs plan must also complete the section specific to that product.
CMS strongly recommends and encourages Medicare Advantage applicants to refer to the 42 CFR Part 422 regulations to clearly understand the nature of the requirement in order to provide an appropriate response. Nothing in this application is intended to supersede the regulations at 42 CFR Part 422. Failure to reference a regulatory requirement in this application does not affect the applicability of such requirement, and Applicants are required to comply with all applicable requirements of the regulations in Part 422 of 42 CFR. Applicants must read HPMS notices and visit the CMS web site periodically to stay informed about new or revised guidance documents.
SECTION 1 ALL MA APPLICANTS (CCP, PFFS, RPPO, & MSA)
1.1 Experience & Organization History
In HPMS, upload a brief summary of the applicant’s history, structure and ownership. Include organizational charts to show the structure of ownership, subsidiaries, and business affiliations.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ADMINISTRATIVE MANAGEMENT |
YES |
NO |
1. Applicant is applying to operate as a Coordinated Care Plan (HMO, Local PPO, and/or PSO). |
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1.3 State Licensure (For CCP, PFFS, & MSA Applicants Only)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE |
YES |
NO |
● If “Yes,” applicant must provide in HPMS an executed copy of a state licensing certificate and/or the CMS state certification form for each state being request.
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Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.
Note: For states or territories such as Puerto Rico whose licenses renew after June 1, the applicant is required to submit the new license in order to operate as an MA or MA-PD.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: BUSINESS INTEGRITY |
YES |
NO |
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B. If Applicant answered “No” to either question above; provide in HPMS a Business Integrity Disclosure, which contains a brief explanation of each action, including the following:
1.
Legal names of the parties.
2. Circumstances.
3. Status
(pending or closed)
4. If closed, provide the details concerning resolution and any monetary payments, or settlement agreements or corporate integrity agreement.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMPLIANCE PLAN |
YES |
NO |
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(Note: This requirement cannot be delegated to a subcontractor (first tier, downstream, and related entities.).
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Note: All compliance plans must be implemented no later than the effective date of the pending contract. For example: January 1, 2009.
A. In HPMS, in the Contract Management/Contract Information/Contract Data page provide the name/title; mailing address; phone number; fax number; and email address for the following Applicant contacts:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENT: KEY MANAGEMENT STAFF |
YES |
NO |
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Applicant agrees that all staff is qualified to perform duties as assigned.
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Contact |
Name/Title |
Mailing Address |
Phone/Fax Numbers |
Email Address |
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Corporate Mailing |
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CEO – Sr. Official for Contracting |
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Chief Financial Officer |
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Medicare Compliance Officer |
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Enrollment Contact |
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Medicare Coordinator |
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System Contact |
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Customer Service Operations Contact |
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General Contact |
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User Access Contact |
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Backup User Access Contact |
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Marketing Contact |
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Medical Director |
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Bid Primary Contact |
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Payment Contact |
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HIPAA Security Officer |
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HIPAA Privacy Officer |
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CEO- CMS Administrator Contact |
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Quality Director |
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B. Provide in HPMS, position descriptions for the key management staff and an organizational chart showing the relationships of the various departments.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: FISCAL SOUNDNESS |
YES |
NO |
(Note: All applicants with three months or less of operations must provide CMS with a financial plan (discussed in section 2. below). |
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In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area the applicant wish to serve.
B. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: SERVICE AREA |
YES |
NO |
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C. Provide in HPMS, detailed maps of the requested service area showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. Maps should indicate contracted ambulatory and hospital providers, and mean travel times.
note: RPPO applicants geographic maps should be defined by rural and urban areas (include borders) that demonstrate the locations of all contracted providers in relation to the beneficiaries in those areas.
1.9 Provider Contracts & Agreements
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PROVIDER CONTRACTS & AGREEMENTS |
YES |
NO |
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Provide in HPMS a completed “CMS Provider Arrangements by County Table”. Applicant should insert the number of provider contractcontracts and/or agreements for each proposed service area or distinctive system(s) applicant.
Provide in HPMS a sample copy of each primary provider contract(s) and agreement(s) between the applicant and its health care contractors (i.e., direct contract with physicians, medical group, IPA, PHO, hospitals, skilled nursing facilities, etc.).
Provide in HPMS, a sample copy of each downstream subcontract that may exist between a Medical groups, IPAs, PHO, etc. and other providers (i.e., individual physicians). (For example: If the applicant contracts with an IPA, which contracts with individual physicians the applicant must provide in HPMS a sample copy of the contract/agreement between the IPA and physicians).
Provide in HPMS, a completed “CMS Provider Participation Contracts and/or Agreements Matrix”, which is a crosswalk of CMS regulations to provider contracts and/or agreements. Applicant should complete a matrix for each applicable primary contracted provider and subcontracted provider.
1.10 Contracts for Administrative & Management Services
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE & MANAGEMENT SERVICES |
YES |
NO |
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B. In HPMS, complete the table below.
DELEGATED BUSINESS FUNCTION |
SUBCONTRACTOR(S) (Just include first tier for now and have downstream available upon request) |
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C. Applicant must provide in HPMS, executed delegated administrative services/management contracts or letters of agreement for each contractor or subcontractor (first tier, downstream, and related entities) identified in the chart (Section 1.10 4.B) above that:
Clearly identify the parties to the contract (or letter of agreement).
Describes each of the specific functions (health and/or administrative) that are now or will be delegated to medical groups, IPAs, or other intermediate entities.
Describes how the applicant will remain accountable for any functions or responsibilities that are delegated to other entities.
Describes how the applicant will oversee, and formally evaluate delegated entities.
Describes the applicant's relationships to related entities, contractors and sub-contractors with regard to provision of health and/or administrative services specific to the Medicare product.
Contains language clearly indicating that the delegated entity, contractor, or subcontractor (first tier, downstream, and related entities) has agreed to perform the health and/or administrative service, and clauses requiring their activities be consistent and comply with the Applicant’s contractual obligations.
Are signed by a representative of each party with legal authority to bind the entity.
Contains language obligating the contractor or subcontractor (first tier, downstream, and related entities) to abide by all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 422 (504)(i)(4)(v).
Contains language obligating the subcontractor (first tier, downstream, and related entities)to abide by State and Federal privacy and security requirements, including the confidentiality and security provisions stated in the regulations for this program at 42 CFR §422.504(a)(13).
Contains language ensuring that the contractor or subcontractor (first tier, downstream, and related entities) will make its books and other records including medical records and documentation involving transactions related to CMS’ contract with the MA organization available in accordance with 42 CFR 422.504 (i) (2). Generally stated these regulations give HHS, the Comptroller General, or their designees the right to inspect, evaluate and audit books and other records and that these rights continue for a period of 10 years from the final date of the contract period or the date of audit completion, whichever is later. Language must be included to specify whether the applicant and the subcontractor have agreed that CMS or its designees may have direct access to the subcontractor’s records (e.g. on-site access to the subcontractor).
Contains language that the subcontractor (first tier, downstream, and related entities) will ensure that beneficiaries are not held liable for fees that are the responsibility of the MA contractor in accordance with 42 CFR 422.504(i)(3)(i).
Contains language that if the Applicant, upon becoming a MA contractor, delegates an activity or responsibility to the subcontractor (first tier, downstream, and related entities), that such activity or responsibility is in accordance to 42 CFR 504 (i) (3) and clearly indicates that any books, contracts, records, including medical records and documentation relating to the Part C program will be provided to either the contractor to provide to CMS or will be provided directly to CMS or its designees; and 2) may be revoked if CMS or the MA contractor determines the subcontractor (first tier, downstream, and related entities) has not performed satisfactorily. in accordance with 42 CFR 504(i)(5). The subcontract may include remedies in lieu of revocation to address this requirement.
Contains language specifying that the Applicant, upon becoming a MA contractor, will monitor the performance of the subcontractor (first tier, downstream, and related entities) on an ongoing basis in accordance with 42 CFR 422.504 (i)(1) & (4).
D. Provide in HPMS, a completed “CMS Administrative/Management Delegated Contracting or Arrangement Matrix”.
1.11 Health Services Management & Delivery (For All CCP Applicants including RPPOs, and for PFFS & MSA Applicants offering a network)
A. In HPMS, complete the table below.
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH SERVICES MANAGEMENT (FOR CCP APPLICANTS, AND PFFS & MSA APPLICANTS OFFERING A NETWORK) |
YES |
NO |
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B. Provide in HPMS, completed HSD tables 1 through 5. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
1.12 Quality Improvement Program (CCP & RPPOS ONLY)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: QUALITY IMPROVEMENT PROGRAM (CCP & RPPOS ONLY) |
YES |
NO |
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MARKETING |
YES |
NO |
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1.13.2 Enrollment, Disenrollment, and Eligibility
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ENROLLMENT, DISENROLLMENT, AND ELIGIBILITY |
YES |
NO |
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In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: WORKING AGED MEMBERSHIP |
YES |
NO |
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In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS |
YES |
NO |
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In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MINIMUM ENROLLMENT |
YES |
NO |
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1.15 Communication between Medicare Advantage Plan and CMS
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMMUNICATION BETWEEN MEDICARE ADVANTAGE PLAN AND CMS |
YES |
NO |
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In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: GRIEVANCES |
YES |
NO |
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Note: A grievance is any complaint or dispute, other than one that involves a organizationcoverage determination, expressing dissatisfaction with any aspect of a MA organization’s operations, activities, or behavior, regardless of whether remedial action is requested. Examples of subjects of a grievance include, but are not limited to:
Timeliness, appropriateness, access to, and/or setting of services provided by the MA organization
Concerns about waiting times, demeanor of providers or customer service staff.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: APPEALS |
YES |
NO |
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Date of receipt; Date of any notification; Disposition of request; and Date of disposition
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: APPEALS |
YES |
NO |
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1.18 Health Insurance Portability and Accountability Act of 1996 (HIPAA) and CMS issued guidance 07/23/2007 and 8/28/2007; 2008 Call Letter
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) |
YES |
NO |
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In HPMS complete the table below;
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: |
YES |
NO |
1. Applicant agrees not to use an enrollee’s Social Security Number (SSN) or Medicare ID Number on the enrollee’s identification card. |
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C. Provide in HPMS a complete “Data Use Attestation”
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTINUATION AREA |
YES |
NO |
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1.20 Medicare Advantage Certification
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MEDICARE ADVANTAGE CERTIFICATION |
YES |
NO |
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NOTE: Based on the type of application submission indicated by MAO once the Part C application is complete; applicant must complete a Part D application/module in HPMS. Note: PFFS organizations have the option to offer a Part D plansPart D plans. MSAs are not allowed to offer Part D.
SECTION 2 REGIONAL PREFERRED PROVIDER ORGANIZATION (RPPO) APPLICANTS ONLY
Note: A RPPO applicant may apply as a signal entity or as a joint enterprise. Joint Enterprise applicants must provide as part of their application a copy of the agreement executed by the State-licensed entities describing their rights and responsibilities to each other and to CMS in the operation of a Medicare Part D benefit plan. Such an agreement must address at least the following issues:
Termination of participation in the joint enterprise by one or more of the member organizations; and
Allocation of CMS payments among the member organizations.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE RPPO |
YES |
NO |
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Provide in HPMS, a complete “CMS State Licensing Status for MA Regional PPO Table” for each MA Region.
Provide in HPMS, a signed” CMS State Licensure Attestation for MA Regional PPOs”
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS STANDARDS |
YES |
NO |
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Provide in HPMS, access standards for the following specified provider types, including the percentage of beneficiaries that will fall within the standards and stated in terms of distance and time (___% of beneficiaries fall within xx miles/xx minutes of 2 Primary Care Providers):
Contracted Hospitals with Full Emergency Facilities
Contracted Primary Care Providers
Contracted Skilled Nursing Facilities
Contracted Home Health Agencies
Contracted Ambulatory Clinics
Contracted Providers of End Stage Renal Disease Services
Contracted Outpatient Laboratory and Diagnostic Services
Contracted Specialists in the following areas:
General Surgery
Otology/Laryngology/Rhinology
Anesthesiology
Cardiology
Dermatology
Gastroenterology
Internal Medicine
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Psychiatry/Mental Health
Pulmonary Disease
Urology
Chiropractic
Optometry
Podiatry
Provide in HPMS, a chart listing all counties (or other units of analysis as relied upon by applicant in establishing standards) and indicate whether each county meets or does not meet each contracted access standard for a contracted provider type.
Provide in HPMS, an access plan describing the applicants proposed mechanism for ensuring beneficiary access to the identified type(s) of provider(s) for each are in which the applicant does not meet its access standards through it contracted network. Access plans may include requests for essential hospital designations, facilitating enrollee access to non-contracted providers at preferred cost sharing levels, or other proposed mechanisms as approved by CMS.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ESSENTIAL HOSPITAL |
YES |
NO |
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Provide in HPMS, a completed “CMS Essential Hospital Designation Table”.
Provide in HPMS, a completed “CMS Attestation Regarding Designation of Essential Hospitals”.
SECTION 3 PRIVATE FEE FOR SERVICE (PFFS) APPLICANTS ONLY
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS TO SERVICES |
YES |
NO |
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DROP
DOWN BOX WITH THE FOLLOWING SERVICES:
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Provide in HPMS, completed HSD tables 1 through 5 for network model PFFS plans. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
Provide in HPMS, a description on how the applicant will follow implement CMS’s national coverage decisions and written decision of carriers and intermediaries (LMRP) throughout the United States. [in the geographic area in which services are covered under the MA Plan (see Refer to 42 CFR 422.101 (b))].
Provide in HPMS, a description on how applicant’s policies will ensure that health services are provided in culturally competent manner to enrollees of different backgrounds.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS PROCESSING |
YES |
NO |
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In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PAYMENT PROVISIONS |
YES |
NO |
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B. Provide in HPMS, a completed Reimbursement grid. (Note: Applicant can use CMS model payment guidance)
SECTION 4 MEDICAL SAVINGS ACCOUNTS (MSA) & MSA DEMO APPLICANTS ONLY
Note: MSA applicants must complete section four, in addition the applicant may have to complete questions in the “ Section 3: section three “Private Fee for Service” section of this application depending upon the type of delivery system that the applicant will offer under the MSA product.
Note: MSA plans cannot offer the Part D drug benefit.
Note: MSA Demonstration Addendum – If the applicant intends to participate in the MSA Demonstration, the Applicant must complete both sections 4 & 5.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: GENERAL ADMINISTRATION/MANAGEMENT |
YES |
NO |
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4.2 Access to Services (See Section 3.1 if Using
A. In HPMS, complete the PFFS Model) table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS TO SERVICES |
YES |
NO |
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B. Provide in HPMS, HSD tables 1 through 5 for network MSA model. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS SYSTEMS & PAYMENT |
YES |
NO |
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A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PAYMENT PROVISIONS |
YES |
NO |
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Note: This only applies to applicants that allow balance billing. |
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B. Provide in HPMS, a completed Reimbursement grid. (Note: Applicant can use CMS model payment guidance)
SECTION 5 MSA DEMONSTRATION APPLICANTS ONLY
5.1 MSA Demonstration Addendum
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MSA DEMONSTRATION ADDENDUM |
YES |
NO |
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B. Provide in HPMS, the following:
Description of any differential in cost-sharing for supplemental benefits from the standard Medicare A/B benefits and for in-network and out-of-network services.
Description of the preventive services that will have full or partial coverage before the deductible is met.
Figures on projected enrollment and the characteristics of beneficiaries who are most likely to enroll in the applicant’s plans (for example, what type of Medicare coverage do they currently have?).
Description of non-Medicare covered preventive services and whether or not any cost-sharing for these services will apply to the plan deductible.
Description of the frequency of periodic deposits and how the applicant will address cases where the enrollee incurs high health costs early in the year.
Description on how the applicant will track enrollee usage of information provided on the cost and quality of providers. Be sure to include how you intend to track use of health services between those enrollees who utilize transparency information with those who do not.
Description on how the applicant will recover current-year deposit amounts for members who are disenrolled from the plan before the end of the calendar year.
PART 3 SERVICE AREA EXPANSION APPLICATIONS
Organizations that may use this application are HMOs; Local PPOs, State Licensed PSOs; PFFS, and MSA organizations.
SECTION 1 ALL MA APPLICANTS (CCP, RPPO, PFFS, & MSA)
Enter contract number in HPMS under the Contract/Management Module.
1.2 State Licensure (CCP, PFFS, & MSA Applicants Only)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS. |
YES |
NO |
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Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.
1.3 Provider Contracts & Agreements
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR PROVIDER CONTRACTS & AGREEMENTS |
YES |
NO |
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Provide in HPMS a completed “CMS Provider Arrangements by County Table”. Applicant should insert the number of provider contract and/or agreements for each proposed service area or distinctive system(s) applicant.
Provide in HPMS a sample copy of each category of provider contract(s) and agreement(s) between the applicant and its primary health care contractors.
Provide in HPMS a sample copy of each subcontract between Medical groups, IPAs, PHO, etc. including their subcontracting providers.
Provide in HPMS a completed, “Provider Participation Contracts and/or Agreements”, a crosswalk of CMS regulations to provider contracts and/or agreements. Prepare a table for each contracted and subcontracted provider.
1.4 Contracts for Administrative & Management Services
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE & MANAGEMENT SERVICES |
YES |
NO |
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B. In HPMS, complete the table below.
DELEGATED BUSINESS FUNCTION |
SUBCONTRACTOR(S) ( Just include first tier for now and have all downstreams available upon request). |
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C. Applicant must provide in HPMS, executed delegated administrative services/management contracts or letters of agreement for each contractor or subcontractor (first tier, downstream, and related entities) identified in the chart (Section 1.4.B) above that:
Clearly identify the parties to the contract (or letter of agreement).
Describes each of the specific functions (health and/or administrative) that are now or will be delegated to medical groups, IPAs, or other intermediate entities.
Describes how the applicant will remain accountable for any functions or responsibilities that are delegated to other entities.
Describes how the applicant will oversee, and formally evaluate delegated entities.
Describes the applicant's relationships to related entities, contractors and sub-contractors with regard to provision of health and/or administrative services specific to the Medicare product.
Contains language clearly indicating that the delegated entity, contractor, or subcontractor (first tier, downstream, and related entities) has agreed to perform the health and/or administrative service, and clauses requiring their activities be consistent and comply with the Applicant’s contractual obligations.
Are signed by a representative of each party with legal authority to bind the entity.
Contains language obligating the contractor or subcontractor (first tier, downstream, and related entities) to abide by all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 422 (504)(i)(4)(v).
Contains language obligating the subcontractor (first tier, downstream, and related entities) to abide by State and Federal privacy and security requirements, including the confidentiality and security provisions stated in the regulations for this program at 42 CFR §422.504(a)(13).
Contains language ensuring that the contractor or subcontractor (first tier, downstream, and related entities) will make its books and other records available in accordance with 42 CFR 422.504(i) (2). Generally stated these regulations give HHS, the Comptroller General, or their designees the right to inspect, evaluate and audit books and other records and that these rights continue for a period of 10 years from the final date of the contract period or the date of audit completion, whichever is later.
Contains language that the subcontractor (first tier, downstream, and related entities) will ensure that beneficiaries are not held liable for fees that are the responsibility of the MA contractor in accordance with 42 CFR 422.504(i)(3)(i).
Contains language that if the Applicant, upon becoming a MA contractor, delegates an activity or responsibility to the subcontractor (first tier, downstream, and related entities), that such activity or responsibility may be revoked if CMS or the MA contractor determines the subcontractor (first tier, downstream, and related entities) has not performed satisfactorily in accordance with 42 CFR 504(i)(5). The subcontract may include remedies in lieu of revocation to address this requirement.
Contains language specifying that the Applicant, upon becoming a MA contractor, will monitor the performance of the subcontractor (first tier, downstream, and related entities) on an ongoing basis in accordance with 42 CFR 422.504 (i)(1) & (4).
D. Provide in HPMS, a completed “CMS Administrative/Management Delegated Contracting or Arrangement Matrix”.
1.5 Health Services Delivery (HSD)
A. In HPMS, complete the table below.
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR HEALTH SERVICES DELIVERY |
YES |
NO |
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B. Provide in HPMS and as appendices, HSD tables 1 through 5. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
A. In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area you plan to serve.
B. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR SERVICE AREA. |
YES |
NO |
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C. Provide as an attachment detailed maps of the requested service area showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. Maps should indicate contracted ambulatory and hospital providers, and mean travel times.
note: RPPO applicants geographic maps should be defined by rural and urban areas (include borders) that demonstrate the locations of all contracted providers in relation to the beneficiaries in those areas.
SECTION 2 SERVICE AREA EXPANSIONS FOR RPPO APPLICANTS ONLY
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE RPPO |
YES |
NO |
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Provide in HPMS, a complete “CMS State Licensing Status for MA Regional PPO Table” for the SAE MA Region.
Provide in HPMS, a signed” CMS State Licensure Attestation for MA Regional PPOs”
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.
Note: For states or territories such as Puerto Rico whose licenses renew after June 1, the applicant is required to submit the new license in order to operate as an MA or MA-PD.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS STANDARDS |
YES |
NO |
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Provide in HPMS, access standards for the following specified provider types, including the percentage of beneficiaries that will fall within the standards and stated in terms of distance and time (___% of beneficiaries fall within xx miles/xx minutes of 2 Primary Care Providers):
Contracted Hospitals with Full Emergency Facilities
Contracted Primary Care Providers
Contracted Skilled Nursing Facilities
Contracted Home Health Agencies
Contracted Ambulatory Clinics
Contracted Providers of End Stage Renal Disease Services
Contracted Outpatient Laboratory and Diagnostic Services
Contracted Specialists in the following areas:
General Surgery
Otology/Laryngology/Rhinology
Anesthesiology
Cardiology
Dermatology
Gastroenterology
Internal Medicine
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Psychiatry/Mental Health
Pulmonary Disease
Urology
Chiropractic
Optometry
Podiatry
Provide in HPMS, a chart listing all counties (or other units of analysis as relied upon by applicant in establishing standards) and indicate whether each county meets or does not meet each contracted access standard for a contracted provider type.
Provide in HPMS, an access plan describing the applicants proposed mechanism for ensuring beneficiary access to the identified type(s) of provider(s) for each are in which the applicant does not meet its access standards through it contracted network. Access plans may include requests for essential hospital designations, facilitating enrollee access to non-contracted providers at preferred cost sharing levels, or other proposed mechanisms as approved by CMS.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ESSENTIAL HOSPITAL |
YES |
NO |
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Provide in HPMS, a completed “CMS Essential Hospital Designation Table”.
Provide in HPMS, a completed “CMS Attestation Regarding Designation of Essential Hospitals”.
PART 4 SOLICITATIONS FOR PECIAL NEEDS PLAN PROPOSAL PLAN
NOTE: For the
Under the MMA (Section 231), Congress provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dualdually eligible (entitled to medical assistance under a State plan under Title XIX); and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary. Authority to offer a Special Needs Plan (SNP) ends on January 1, 2009 MA contracting year, CMS is not accepting any Special Needs Plans (SNP) proposals. The application system in CMS' HPMS will not be available to applicants to upload SNP proposal applications.
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On December 29, 2007, the President signed into law the Medicare, Medicaid, and SCHIP Extension Act of 2007 [42 U.S.C. 1395w-21(b)(1) and (2) of the Social Security Act]. Section 108 of the statute extended the SNP enrollment authority to December 31, 2009, with a moratorium on all SNPs and SNP enrollment expansion. The statute precludes the designation of MA plans to SNPs after January 1, 2008. In addition, the statute does not allow further SNP enrollment expansion for the 2009 MA contracting year except in the SNPs’ service areas which were open for enrollment on January 1, 2008.
The material that
Organizations that follows is the required documentation had there not been a moratorium on SNPs.
PART 4 SOLICITATIONS FOR SPECIAL NEEDS PLAN PROPOSAL PLAN
Under the MMA (Section 231), Congress provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dual eligible (entitled to medical assistance under a State plan under Title XIX); and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary.
Current SNP authority will expire at the end of 2008 unless legislation reauthorizing it is passed. In anticipation that intend to offer SNPs may be extended, to,must provide a SNP proposal(s) must be filed by the MA application due date, March 10, 2008, in order for CMS to consider an organization to initially offer or expand an existing SNP(s) in 2009.
MA applicants and contracting MAs, intending to initially offer or expand an existing SNP(s), must complete and submit a SNP proposal(s) to CMS that includes required information as prompted below for each type of SNP the organization expectintends to offer. This solicitation for SNP proposals is divided into the following sections:
General Guidance on Completing SNP Proposal
Requirements to Submit a SNP Proposal -- MA and Part D Applications May Also Be Required
A. Seeking New Medicare Coordinated Care Plan (CCP) Contract that Includes SNPs
B. Adding SNPs under Existing Medicare CCP Contract – Service Area Unchanged
C. Adding SNPs under Existing CCP Contract – Service Area Changing
D. Procedure for Minimizing Duplication, Including Across Multiple MA-PD Contracts
Key Definitions
Template for Completing SNP Proposal
A. Dual Eligible SNP Type
B. Institutional SNP Type
C. Severe or Disabling Chronic Condition SNP Type
Attachments:
A: Subsets for Dual Eligible SNPs
B: SNP Service Area Table
C: Ensuring Delivery of Institutional SNP Model of Care
D: Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
E: Quality Measurements for Special Needs Plans
F: Crosswalks for Consolidating SNP Proposals for Multiple Contracts
G: Dialysis Facilities Table
H: Transplant Facilities Table
I: Long Term Care Facilities Table
J: Additional Option for Pre-enrollment Verification of Chronic Condition for Chronic Condition Special Needs Plans
K. Severe or Disabling Chronic Conditions List – 2008-2009 Crosswalk
The SNP proposal applicant must follow the step by step instructions in Section 4 to propose the type of SNP the applicant intends to offer. Sections 4.IV. A,,. B,,. and C. offer prompts for each SNP type, and 4.D. contains the consolidated Model of Care with certain stipulations for additional information on specific SNP types. If the applicant is seeking approval for more than one type of SNP, then the template for the proposal should be completed for each of those types. The applicant’s responses must be provided within the Section 4 template except as instructed in the template to provide an attachment. Do not provide narrative or other information as an attachment unless instructed to do so. The responses to the template as well as the attachments and the documentation for the State and long term care contract should all be in a single Microsoft word document. All documents request in template should be provided in HPMS as a PDF File. The end result should be only one electronic file. The applicant must complete and submit the SNP proposal, as an upload zip file, e submitted to the HPMS. See the HPMS Part C Application User guide for step by step upload instructions. The end result should be only one electronic zip file uploaded to the HPMSCMS for a SNP proposal, which contains all the required data and information, for each SNP type, i.e. dual, chronic or institutional.
A SNP proposal responding to this solicitation for the next contract cycle beginning January 1, 2009 will not be considered by CMS unless the solicitation is submitted by the deadline for MA applications. The application deadline is March 10, 2008. Late proposals, including additional requests forwhen a certain SNP type (for example, any additional proposed dual eligible subsets), will not be accepted after the MA application deadline. Other associated MA and Part D applications must also be provided; see Section 2 for instructions on what other applications may be required.
If the applicant has questions about the SNP program or about completing this proposal, please send an e-mail to the following address: [email protected]. To ensure that the applicant’s question is forwarded to the appropriate CMS staff, the subject line of the e-mail must include the phrase “SNP Proposal” and must also include the applicant name and CMS contract number(s).
A. Applicants seeking linitialSeeking New Medicare Coordinated Care Plan (CCP) contractContract that include a SNP(s)Includes SNPs
An applicant Organizations that does not have a current CCP MA contract with CMS must complete and submit the following applications:
1. Complete and submit to CMS the full Coordinated Care Plan (CCP) MA application and SNP proposal.in order to offer a Special Needs Plan (SNP). The MA application is posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/ and should be submitted as described in the MA application. The SNP proposal is contained within the MA application. The completed SNP proposal is. In addition, an upload to the HPMS as a zip applicant must offer Part D under the SNP products, and must file for each SNP type, i.e. dual, chronic or institutional.. See the HPMS Part C Application User guide for step by step instructions.
2. The appropriate Part D application. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance.
The MA application should be submitted as described in the MA application. The Part D application should be submitted per the instructions provided in the Part D application.
B. Contracting MA adding or expanding a SNP(s) with no change in the MA’s existing service areaAdding SNPs under Existing Medicare CCP Contract – Service Area Unchanged
A contracting MA, who wants to offer a SNP(s) or expand an existing SNP(s) in an approved existing service area, must complete and submit a SNP proposal to CMS. The SNP proposal is contained within the MA application which is posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/. The completed SNP proposal is an upload to the HPMS as a zip file for each SNP type, i.e. dual, chronic or institutional... See the HPMS Part C Application User guide for step by step instructions.
The SNP proposal must include the required information for each SNP type, including subset(s), being offered by the MA. For example, if the MA is seeking to offer a dual eligible SNP to serve a specific Medicaid population in coordination with a State Medicaid contract and that subset has not been previously approved by CMS, then the MA must submit a SNP proposal for a Medicaid subset to CMS. Similarly, if a dual eligible SNP has previously been approved and the applicant intends to offer a different dual eligible subset type, chronic or institutional SNP, not previously approved, then the SNP proposal must include the required information for each SNP type for which prior CMS approval has not been granted.An applicant may propose offering a SNP type not already approved by CMS under an existing Medicare CCP contract, wherein the service area of that contract will be unchanged. Under these circumstances, A SNP proposal must be submitted to CMS via HPMS. For example, if the applicant is seeking to offer a SNP to serve a specific subset of dual eligibles in coordination with a State Medicaid contract and that subset has not been previously approved by CMS, then a SNP proposal requesting such subset must be submitted to CMS via HPMS. Similarly, if a dual eligible SNP has previously been approved and the applicant intends to offer a chronic or institutional SNP not previously approved, then a SNP proposal must be submitted to CMS via HPMS for each SNP type for which prior CMS approval has not been granted. The applicant should complete the SNP portion of the MA application for each subset requested in HPMS.
When a MA addsan applicant seeks to add a SNP to its current service area under an existing MA contract, it must also offer prescription drug coverage under Part D. If the applicant already offers Part D along with its Medicare Advantage product in the current service area, it does not need to file a new Part D application. It must maintain its prescription drug coverage by submitting a formulary and bid. If Part D coverage is not part of the applicant’s MA contract, the appropriate Part D application must be completed and submitted to CMS by the specified due date per the instructions provided in the Part D application by March 10, 2008. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance”.
C. Contracting MA adding a SNP(s) or expanding an existing SNP service area to a MA Service Area Expansion (SAE) Adding SNPs under Existing CCP Contract – Service Area Changing
A contracting MA, who wants to offer a SNP or expand an existing SNP service area in a MA An applicant may expand its service area under an existing MA contract and seek to offer a SNP in the expanded service area. To do this the applicant must complete a service area expansion (SAE) must complete and submit to CMS a SAE application for MA contracts and a SNP proposal. The SNP proposal is contained within the MA application which isapplications are posted at::: http://www.cms.hhs.gov/MedicareAdvantageApps/. The completed SNP proposal is an upload to the HPMS as a zip file for each SNP type, i.e. dual, chronic or institutional.. See the HPMS Part C Application User guide for step by step instructions.
The MA SAE application should be submitted as described in the MA application. IfIn addition, if the MA applicant does not currently offer prescription drug coverage in the service area to be covered under the MA contract number then, the applicant must must also file the appropriate separate Part D application. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ Click Clickand click on “Application Guidance”.
D. Procedure for Minimizing Duplication, Including Across Multiple MA-PD Contracts
There are at least three circumstances in which there could be duplicate information in the applicant’s proposal if it were required to provide an individual SNP approval request for each SNP it wishes to offer. These are listed below with instructions for how this duplication can be minimized. Only these specific instructions can be followed to minimize duplication. Any other approach will not be accepted by CMS.
1. A request is made for the approval of multiple SNPs under a single contract across some combination of dual eligible, institutional and severe or disabling chronic condition SNPs.
Instruction: Each section of the template must be completed in its entirety. For multiple requests within a SNP type of SNP follow instructions under 2. below.
2. A request is made for the approval of more than one targeted population within a SNP type under the same contract. Examples include all dual, full dual duals only and Medicaid subset; institution and community based institutional beneficiaries in separate SNP; and different chronic diseases each in separate SNPs.
Instruction: Within Section 4. A, B, and C, and D, follow the instructions embeddedimbedded in the template that allow certain elements not to be repeated if they are the same in other populations defined under the same Section 4. A, B, or C, or D. To summarize, for each population, the applicant may copy the template but only provide the elements where there is a change, rather than provide complete responses for each SNP request.
3. A request is made under multiple MA-PD contracts for one or more SNPs. The applicant may follow the instructions below rather than provide multiple complete responses for every SNP request.
Instructions for Completing the SNP Solicitation for Proposals Across Multiple MA-PD Contracts
If the applicant is requesting, under multiple MA-PD contracts, a uniform SNP Model of Care for any of the three SNP types – for dual, institutional, or severe or disabling chronic condition individuals, then the applicant may submit a SNP type-specific baseline proposal to CMS and consolidate the applicant’s responses on all SNP plan requests related to that baseline SNP proposal.
For the purpose of the SNP solicitation and understanding how to consolidate responses under a SNP proposal, a “plan” is a unique combination of a targeted population and Model of Care, as defined in Section 3 under MA contract number. For example, as instructed in Section 4, if an organization under contract H9999 intends to offer a full dual SNP and a further subsetsubsetted dual SNP, then the applicant would requestbe requesting two dual SNPs under H9999, and these “plans” would be labeled as follows (and as instructed in Section 4 of the SNP solicitation): H9999_ A_Plan_1, and H9999_A_Plan_2, where A represents a dual eligible SNP request..
The baseline proposal must contain SNP Model of Care information common to all SNP plans of a specific type (i.e., dual, institutional, or severe or disabling chronic condition) as prompted in Section 4.D. In addition, the applicant must submit supplemental addendums for each requested SNP plan of the particular type (i.e., dual, institutional, or severe or disabling chronic condition) along with the baseline proposal. The addendum would contain a discussion of those elements in Section 4 for which the applicant determines the complete answer deviates from the baseline proposal. For selected elements in Section 4, the applicant is required to provide complete information in the same supplemental addendum for each plan of that SNP type, regardless of whether it reflects any duplication. Finally, along with the baseline proposal the applicant must provide a table that crosswalks each contract and plan number (as numbered in Section 4) indicating with a check mark those elements in Section 4 that deviate from the baseline proposal.
This consolidated response and the crosswalk must be completed separately for each SNP type (i.e., dual, institutional, or severe or disabling chronic condition). For example, if across multiple contracts the applicant requests both dual and institutional SNPs, then the applicant would provide two consolidated proposals, one for dual and one for institutional SNPs. The only alternative would be to complete a SNP proposal for each contract as Section 4 directs.
The specific steps that must be followed to submit a consolidated SNP proposal across multiple contracts are:
Step 1: The baseline SNP proposal is the applicant’s description of the basic Model of Care used for multiple SNPs of a selected type (i.e., dual, institutional, or severe or disabling chronic condition). Develop the baseline SNP proposal(s). This is the document that provides all the detailed information on the SNP type and Model of Care requested by CMS in the “Solicitation for Special Needs Plan Proposal” as follows:
Dual SNP: Section
4, A.2, A.5, A.7 through A.9
Institutional SNP:
Section 4, B.2, B.2.c,B.2.d, B.4, B.6.a through B.9
Chronic SNP:
Section 4, C.2, C.4, C.6 through C.8
For those elements required by CMS for each SNP plan, the baseline proposal should reference “see supplemental addendum for specific SNP plan”. Those elements include number assignments for each SNP type, relationship to State Medicaid services in the event of subsets, State contracts information if other than subsets, and service area. The specific location of these elements is as follows:
Dual SNP: Section 4, A.1, A.3, A.4, A.6.
Institutional SNP: Section 4, B.1, B.3 and B.5
Chronic SNP: Section 4, C.1, C.3, C.5
Step 2: Develop a supplemental addendum for each SNP plan covered under the baseline SNP proposal. The supplemental addendum is information pertaining to the specific SNP plan. The SNP plan name should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), Plan, X (where “X” is the number of the SNP plan in the SNP proposal), with an underscore between each element (Hxxxx_X_Plan_X). An example is “H9999_A_Plan_1”. Two types of information must be provided. For the following elements modify or replace information that is different from the baseline SNP proposal:
Dual SNP: Section
4, A.2, A.5, A.7 through A.9.
Institutional SNP:
Section 4, B.2, B.2.c, B.2.d, B.4., B.6.a through B.9
Chronic SNP:
Section 4, C.2, C.4, C.6 through C.8.
For the following elements a complete answer must be provided for each
SNP plan regardless of possible duplication:
Dual SNP: Section 4, A.1, A.3, A.4, A.6.
Institutional SNP: Section 4, B.1, B.3 and B.5
Chronic SNP: Section 4, C.1, C.3, C.5
To provide this information, complete Section 4 A, B or C and copy the template as many times as there are requests within a Section A, B, C. Except for required responses for each SNP plan, only elements that are different from the baseline proposal should be represented.
Step 3: Complete one crosswalk for each baseline SNP proposal (i.e., dual, institutional, or severe or disabling chronic condition), listing each contract/plan number combination associated with the baseline SNP proposal as demonstrated below. Provide the following information:
1. Applicant’s contracting name (as provided in HPMS)
2. Date submitted to CMS
3. Name of the baseline SNP proposal. The baseline name should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional and C = severe or disabling chronic condition), Baseline, X (where “X” is the number of the baseline SNP proposal), with an underscore between each element. An example is “H9999_A_baseline_1”.
4. For each SNP plan covered by the baseline SNP proposal
a) Contract number (provided by HPMS)
b) Plan number (as required in Section 4 of the SNP solicitation, for example A_Plan_2)
c) Check all elements that deviate from or provide additional information relative to the baseline SNP proposal. All checked elements must be addressed in the supplemental addendum for the specific SNP plan. CMS requires a complete response in the addendum for those elements that are pre-checked in the template crosswalks provided in Attachment F. The crosswalks must be used in the format and structure provided.
The filename of the SNP baseline proposal must be the same as the SNP baseline name as outlined in Step 3 above. The baseline filename should be the CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), baseline, X (where “X” is the number of the baseline SNP proposal), with an underscore between each element. An example is “H9999_A_Baseline_1”.
The filename of each plan addendum must be the same as the plan addendum name as outlined in Step 2 above. Each filename should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional and C = severe or disabling chronic condition), Plan, X (where “X” is the number of the SNP plan), with an underscore between each element (Hxxxx_X_Plan_X). An example is “H9999_A_Plan_1”.
NOTE to Applicant: CMS will not accept consolidated proposals across contracts under any other format. The only other alternative is to complete a SNP proposal for each MA-PD contract.
The following key definitions are provided here to assist the applicant in ensuring that the SNP types proposed and populations targeted for the plan offerings represented in this proposal are allowable.
Specialized MA plan for special needs individuals: Any type of MA coordinated care plan that exclusively enrolls or enrolls a disproportionate percentage of special needs individuals as set forth in 42 CFR 422.4(a)(1)(iv) that provides specialized care to such individuals, and that provides Part D benefits under 42 CFR Part 423 to all enrollees.
Special needs individual: An MA eligible individual, who is institutionalized, as defined below, is entitled to medical assistance under a State plan under title XIX, or is an individual with a severe or disabling chronic condition recognized by the Secretary as benefiting from enrollment in a specialized MA plan. 42 CFR 422.2
Institutionalized: For the purpose of defining a special needs individual, an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care facility which is a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); or an inpatient psychiatric facility. (42 CFR 422.2). For purposes of SNPs, CMS may also consider as institutionalized those individuals living in the community but requiring an institutional level of care based on a State approved assessment.
Severe or
disabling chronic condition: CMS,
in collaboration with industry experts, has identified several
conditions for which beneficiaries could experience chronically
severe or disabling symptoms or disease progression.
Examples of severe and disabling chronic conditions
areinclude: AIDS, diabetes, congestive heart failure (CHF),
chronic obstructive pulmonary disease (COPD), and chronic mental
illness. A list of severe or disabling chronic conditions currently
used by approved SNP plans is found in Attachment K and on the HPMS
website. (SNP proposals to serve this type of special needs
individual will be evaluated on a case by case basis).
Frailty: Generally recognized definitions of frailty include the following from an article in the Journal of Clinical Epidemiology:
Frailty is defined as [1] a state of reduced physiologic reserve associated with increased susceptibility to disability; and [2] defined as frail those who depend on others for the activities of daily living or who are at high risk of becoming dependent.1
The applicant is encouraged to use one of these or a similar definition in its discussion of the SNP Model of Care.
Disproportionate percentage: A SNP that enrolls a greater proportion of the target group of special needs individuals (i.e. dual eligible, institutionalized, or those with a specified severe or disabling chronic condition))))), than occurs nationally in the Medicare population. This percentage will be based on data acceptable to CMS, including self-reported conditions from the Medicare Current Beneficiary Survey (MCBS) and other data sources. Please consult the following websites for additional information on determining disproportionate percentage.
Risk Adjustment page:
http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/RSD/list.asp#TopOfPage
MCBS page:
http://www.cms.hhs.gov/MCBS/
Medicaid Subsets for Dual Eligible SNPs: A SNP that targets a more narrow population then is otherwise allowed to coordinate services between Medicare and Medicaid. (Attachment A is the subsetting policy).
Full benefit duals: A Full-Benefit Dual Eligible Individual is a Medicare beneficiary who is determined eligible by the State for medical assistance for full benefits under Title XIX of the Social Security Act for the month under any eligibility category covered under the State plan, or comprehensive benefits under a demonstration under section 1115 of the Act , or medical assistance under 1902(a)(10)(C) of the Act (medically needy) or section 1902(f) of the Act (States that use more restrictive eligibility criteria than are used by the SSI program) for any month if the individuals was eligible for medical assistance in any part of the month.
A complete breakdown of dual eligible categories is located at the following website:
http://www.cms.hhs.gov/DualEligible/02_DualEligibleCategories.asp#TopOfPage
Zero cost sharing dual eligibles: This category includes Qualified Medicare Beneficiaries (QMB) and QMB pluses, the two categories of dual eligible beneficiaries that have Medicare A and B cost sharing paid by Medicaid and may include other Medicaid beneficiaries for which the State holds the beneficiary harmless for Medicare A and B cost sharing. Further information on these categories is located at the following website:
http://www.cms.hhs.gov/DualEligible/02_DualEligibleCategories.asp#TopOfPage
Model of Care:
Background
For the SNP program, there are three broad target populations groups – dual eligibles, institutionalized individuals and individuals with severe or disabling chronic conditions. Depending on how specifically the target population is defined, the Model of Care would focus on the unique needs of the targeted population as defined by the applicant (e.g. full benefit dual eligibles, beneficiaries living in the community but requiring an institutional level of care, beneficiaries with congestive heart failure). In addition, for each targeted population, the applicant should address its approach to frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries who are at the end of life, as these subsets are likely to be more prevalent among the special needs populations. As the SNP program is intended to provide specialized services and these beneficiaries are among the most complex to treat, SNP programs are expected to include goals and objectives as well as specialized care for these categories of beneficiaries within the overall Model of Care for individuals who are dually eligible, institutionalized, or have a severe or disabling chronic condition.
Definition
The Model of Care describes the applicant’s proposed approach to providing specialized care to the SNP’s targeted population, including a statement of goals and specific processes and outcome objectives for the targeted population to be managed under the SNP, and differentiates how this plan has added value for special needs populations when compared to other MA plans. An inclusive Model of Care would demonstrate goals and objectives, comprehensive risk assessment, care coordination and case management based on risk stratification, a provider network having specialized experts and a service delivery system pertinent to the target population, a communication network, SNP training for network providers, and a performance measurement and improvement program that evaluates the impact of care on the special needs population.
The Model of Care is in essence the system of care which reflects 1) pertinent clinical expertise and the staff structures; 2) the types of benefits and; 3) processes of care (organized under protocols) that will be used to meet the goals and objectives of the SNP. The Model of Care should be specific enough to imply what process and outcome measures could be used by the applicant to determine if the structures and processes of care are having an intended effect on the target population.
Examples of pertinent clinical expertise and staff structures include clinicians with a certificate to treat individuals with mental illness for a SNP that is targeting beneficiaries with mental illness, or availability and use of nurse practitioners and case managers. Another example is an explanation of how a nursing home staff shall interact with the SNP staff to implement assessment and care management under the SNP.
Examples of types of benefits and processes of care include protocols that drive frequency and character of assessment case and care management, disease management and poly- pharmacy management. Protocols are specific enough to define the beneficiary circumstances or conditions for which a set of actions should be taken.
Follow the step by step instructions below and insert answers directly into the template. The applicant should complete only the portion(s) of the template that correlate to the specific SNP type the applicant intends to offer, i.e. that is Section A, B or C. If the applicant is seeking approval for more than one type of SNP, then the template for the proposal should be completed for each of those types. The responses to the template as well as the attachments and the documentation for the State and long term care contract should all be in a single Microsoft word document. All documents requested in the template mustshould be provided in the zip file uploaded to HPMS as PDF.File. The end result should be only one electronic file should be submitted to CMS for a SNP proposal, which contains all the required data and information. . The final submission to CMS for a SNP proposal should be only one electronic file which contains all the required Data and information.
See Section 2 for instructions to minimize duplication of responses and otherwise follow the instructions in this template. Any other approach to minimizing duplication will not be accepted by CMS.
The following template provides all the necessary prompts for each type of SNP – Section A dual eligible; Section B institutional; and Section C severe or disabling chronic condition SNPs.
If the applicant intends to target populations under a particular SNP type, for example a dual eligible SNP for all dually eligible beneficiaries and a dual eligible SNP for full benefit dual eligible beneficiaries only, then Section A of the template should be completed twice once for each request, Hxxxx_A_Plan_1, Hxxxx_A_Plan_ 2. It is not necessary to repeat information that is the same for each request within the dual eligible SNP. For example in H9999_A_Plan_2, the applicant must complete any portion of the dual eligible section that is different from the first one, H9999_A_ Plan_ 1. For the second requested subset the applicant must indicate that all information is the same as H9999_A_ Plan_ 1 except as provided and the applicant will list the sections that contain additional information and provide the response using the same example. These additional responses must not be embedded in the discussion for H9999_A Plan_1, but rather must follow H9999_A_ Plan_ 1, presenting clearly the applicant’s specific response to H9999_A Plan_ 2, then followed by H9999_ A_ Plan_ 3, etc.
In this same example, assume the applicant is also offering an institutional SNP. All elements must be completed for the first institutional SNP request H9999_B_Plan_1.
Particular attention should be paid to the circumstance of different SNP offerings within a contract service area wherein one SNP covers only a segment of that service area and another covers a different segment. Specifically, if the applicant is seeking to offer a SNP in a limited segment of the contract service area, the applicant is not required to repeat information that will be the same for each segment. However, in any section where the information is not the same, the applicant must complete that information. For example, information about state contracts, service area and provider network could vary with every request. Include the CMS assigned contract number and plan number (e.g. Hxxx_A_ Plan_1, Hxxxx_A_Plan_2) and the type of information contained in the file. For all files use the following nomenclature H9999_x_Plan_x_proposal; H9999_x_Plan_x_contract
DUAL ELIGIBLE SNP TYPE
Number Assignment for each Dual Eligible SNP Type
State whether the applicant is proposing a dual eligible SNP. If no, proceed to Section B.
State how many different dual eligible SNP types are being proposed.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in A.1.b. Duplication can be minimized by following the instructions in Section 2 and IV. 3. Consecutively label each dual eligible SNP type as dual eligible SNP Hxxxx_A_Plan_ 1, Hxxxx_ A_Plan_ 2, etc.
This particular dual eligible SNP type is numbered (insert Hxxx_A_ Plan_ 1, Hxxx_A_ Plan_ 2, etc.)
Type of Dual SNP
Identify what dual eligible population will be served by this SNP:
All Duals: Medicare and Medicaid eligible beneficiaries
Full Duals Only (See definition in Section 3)
Zero Cost Sharing Duals: QMB only and QMB pluses (See
definition in Section 3)
Other Dual Eligibles SubsetEligible Subsets/Requires a State contract. If the State contract is limited to only those beneficiaries the state holds harmless from Medicare Part A and B cost sharing, check the Zero Cost Sharing Duals box as well. (See Attachment A (See Attachment B)
Describe the procedure the applicant will use to verify eligibility of dual eligible individuals through the State.
NOTE to applicant: The applicant must verify an individual’s Medicaid eligibility with the state or through a vendor prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of dual eligible status as this does not reflect the most current State status. The applicant must obtain eligibility status from the respective States.
Relationship of SNP Product to State Medicaid Services in the Event of Other Subsetting
If applicant is not requesting an “Other Dual Eligible Subset” indicate that below and proceed to Section A.4.
NOTE to applicant: If the applicant intends to offer an “Other Dual Eligible Subset” it must be allowable as explained in guidance provided in Attachment A.
Additional subsetting must be approved by CMS and a contract or agreement between the State and the applicant organization must exist and evidence must be provided to CMS by October 1, 2008 in order for the applicant to actually offer such subsetted dual SNPs effective on January 1, 2009.
The deadline for submission of this documentation was extended from the July 1, 2008 date proposed in the draft SNP solicitation to October 1, 2008 to allow applicants additional time to finalize their State contracts. However, an applicant should submit this documentation as soon as it becomes available so CMS can proceed with final approval as quickly as possible. Further, the applicant must submit a bid for the subset population according to existing Medicare Advantage (MA) and Part D prescription drug plan rules and regulations which require that the bid be submitted by the first Monday in June. The bid, including its underlying assumptions about the population to be served, cannot be modified in the event the applicant fails to document entry into a contract with the State by the October 1, 2008 deadline. Final approval of the bid is in part contingent on finalizing the contract with the State and providing the necessary documentation to CMS by October 1, 2008. In addition, certain addenda to the contract will have to be signed.
The applicant should be aware that the October 1, 2008 deadline could affect whether and how the SNP product will be featured in the Medicare & You Handbook, and in the Medicare Plan Finder for at least the first month. CMS approval of marketing materials may also be delayed which could subsequently delay marketing of the new SNP product.
If the proposed subset serves the institutional population and/or those living in the community requiring an institutional level of care, the applicant MUST complete this section as well as ALL portions of Section B that are not addressed by information provided in Section A on dual eligibles. If the proposed subset serves a selected dual eligible population with chronic diseases, the applicant must complete this section as well as all portions of section C that are not addressed by information provided in Section A on dual eligibles.
What specific subset of the dual eligible population does the applicant intend to serve under this SNP?
Provide a list of the types of dual eligible enrollees the applicant does not intend to serve.
Explain how the applicant’s subset of individuals coincides with State efforts to integrate Medicare and Medicaid services for the target population. Specifically, provide an explanation from the State for the subset that also includes a discussion of the Medicaid population that will be served by the SNP. The applicant must include the State’s response with the SNP proposal.
Provide the following documentation to support the subset request and verify the applicant’s relationship with the State Medicaid agency.
A signed contract with a State Medicaid agency to serve the population through the SNP. Include a copy of the title page, the page that includes the eligible Medicaid population and the signature page. If this documentation does not exist, then state this and go to A.3.d.2
If applicant’s organization will have a contract with the State to provide Medicaid services to the requested subset of dual eligible individuals that will be effective by January 1, 2009, include a letter from the State that verifies that information. The letter must verify the requested Medicaid subset including a list of the types of dual eligible beneficiaries eligible for the SNP and an assurance that the applicant will have a contract or agreement with the State Medicaid agency effective on January 1, 2009 that will be signed by October 1, 2008.
Provide the name and contact information of the applicant’s contact person at the State Medicaid agency. If the applicant does not have a Medicaid contract to serve any dually eligible beneficiaries, then proceed to Section A.4.d.
State Contracts Information if Other Subsetting is Not being Requested by Applicant
Identify any contracts between the applicant and the State to provide Medicaid services to the dual eligible population. If the applicant does not have a Medicaid contract, proceed to Section A.4.d.
Describe the population(s) the applicant serves under that Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for the targeted dual eligible population.
If the applicant does not have a Medicaid contract indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name, phone number, e-mail address and mailing address (contact information) of the applicant’s contact person at the State Medicaid agency. If the proposed SNP serves more than one State, provide the contact information for each State.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If the applicant selected exclusive, then proceed to Section A.6.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section 3., propose the reference point to compare the applicant’s targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries not part of the target population (e.g. spouses, beneficiaries who lost their dual eligible status).
State what percentage of the projected enrollment would be the target population.
State what data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
The applicant can submit a SNP proposal in only counties approved or pending approval in the MA contract. The SNP service area can be a subset of the county level approved MA service area. The SNP service area cannot be a subset below the county level approved MA service area. If the approved MA service area is for selected zip codes of a county, the SNP service area must be equal to all the zip codes approved for the MA service area for the county. An exception is a SNP that also includes a Medicaid contract for a geographic area smaller than a county.
Complete a separate Attachment B for each SNP proposal. List the State(s) and County (ies) to be served by the SNP proposal. If the SNP proposal will serve all counties in the State, then Attachment B can list “All Counties” instead of listing the individual counties.
SNP
Model of Care
NOTE to applicant:
Refer to the definition of Model of Care
in Section 3. (clinical expertise required of the Model of Care is
elicited under the provider network Section A.8.)
List the goals and objectives of the Model of Care that
will drive service delivery under this dual eligible SNP. Address
the goals and objectives specific to each of the following:
frail/disabled beneficiaries, beneficiaries with multiple chronic
illnesses, and beneficiaries at the end of life.
Describe the specific organization of staff (e.g.
employees, community service workers, nurse practitioners, case
managers) who interact with dual eligible individuals to provide
the specialized services available under the Model of Care.
Describe the respective roles of the staff as identified in
A.7.b.
Describe the lines of communication and accountability
between the SNP and the staff.
Describe the specific steps the SNP takes (e.g. written
protocols and training) to ensure that the staff understands how
the Model of Care works and to function in accordance with the
Model of Care.
State how this Model of Care will identify and meet the
needs of dual eligible beneficiaries.
List and explain extra benefits and services that will be
provided to meet the needs of dual eligible beneficiaries.
State what specific processes and outcome measures the
applicant will use to measure performance of the Model of Care for
dual eligible beneficiaries. (See Attachment E)
Meeting the Needs of
Frail/Disabled
Enrollees
Provide the applicant’s definition of a frail
enrollee either
using one of the definitions in Section 3 or something similar.
State whether the applicant’s Model of Care
specifically addresses the needs of frail beneficiaries and/or the
needs of enrollees with a disability.
If serving enrollees with disabilities, specify the types
of disabilities the applicant will address through the SNP.
NOTE to applicant: The
response should address at least one of these categories (frail
enrollees, enrollees with disabilities, or both)
Address how the Model of Care will identify and meet the
needs of frail/disabled beneficiaries as defined in A.7.i.1.,
A.7.i.2 and A.7.i.3.
List and explain
extra benefits and
services that will
be provided to meet the needs of frail/disabled
beneficiaries as defined in A.7.i.1., A.7.i.2 and A.7.i.3.
Address what specific
process and outcome measures the plan will use
to measure performance of the Model of Care
for frail/disabled beneficiaries. (see Attachment
E).
Meeting the Needs of
Enrollees with Multiple Chronic Illnesses
Address how the Model of Care will identify and meet the
needs of beneficiaries with multiple chronic illnesses.
List and explain
extra benefits and
services that will
be provided to meet the needs of individuals with multiple chronic
illnesses.
Address what
specific process and outcome measures the plan will
use to measure performance of the Model of Care for
beneficiaries with multiple chronic illnesses. (See Attachment E)
Meeting
the Needs of Enrollees that are at the End of
Life
Address how the Model of Care will identify and meet the
needs of beneficiaries who are at the end of life.
List and explain
extra benefits and
services that will
be provided to meet the needs of individuals facing the end of
life.
Address what
specific process and outcome measures the plan will
use to measure performance of the Model of Care for
beneficiaries facing the end of life. (See Attachment E)
Provider Network
State whether the SNP provider and pharmacy networks are
different than the networks for the applicant’s other
Medicare coordinated care plans (CCP) plans in the same service
area under this contract.
Using the Model of Care described in Section 3 as a guide,
describe the pertinent clinical
expertise that the applicant will use is in the
applicant’s network to
meet the special needs of the dual eligible
population. Also address the pertinent clinical expertise the
applicant believes are necessary in order to meet the needs of
frail/disabled beneficiaries, beneficiaries with multiple chronic
illnesses, and beneficiaries at the end of life.
If the network does not include sufficient specialists to
fully meet the special needs of the target population, describe how
access to non-contracted specialists will be arranged.
Specifically, describe the policies and procedures that will be
followed to make sure enrollees have meaningful access
to all necessary providers.
NOTE to applicant: Although
the applicant is required to respond to
the questions
in the SNP proposal regarding the provider network,
separate
HSD tables are not required unless requested by CMS.
Individuals
with End
Stage
Renal
Disease
State whether the applicant intends to
enroll beneficiaries with end stage renal disease
(ESRD) in its dual eligible SNP. If no, then proceed to Section
A.10.
If the applicant intends to enroll individuals with ESRD
in its dual eligible SNP,
describe how the organization will serve the unique
needs of this population.
List the contracted dialysis facilities in “Attachment
G –Dialysis Facilities”.
List the contracted transplant facilities in “Attachment
H – Transplant Facilities”.
List any additional services that will be provided to
beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment
and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant:
If a SNP is approved to serve ESRD beneficiaries, the exceptions
authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver
pursuant to 42 CFR
422.52 (c) will be provided to the applicant. The
signed waiver will be attached to the MA contract. If this is an
MA organization that is adding a SNP, the waiver will be sent
following final approval and the waiver must be signed and returned
within 10 calendar days. Further, the
applicant may accept a copy of the CMS form 2728,
“ESRD Medical
Evidence
Report
Medicare
Entitlement
and/or Patient
Registration”
as
verification of ESRD status prior to enrollment,
Targeting an Alternative Dual Eligible Population to the One Described Above
NOTE to applicant:
If the applicant also intends to target an alternative dual
eligible population to the one described above, then duplicate the
dual eligible section of the template (Section A)
here and continue
the numbering with A
Plan 2, etc. If the
applicant is not intending to propose any additional dual eligible
SNPS, then proceed to Section B.
INSTITUTIONAL SNP TYPE
Number Assignment for each Institutional SNP Type
State whether the applicant is proposing an institutional SNP. If no, proceed to Section C.
State how many different institutional SNP types the applicant is proposing to offer.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in B.1.b. Consecutively label each institutional SNP type as institutional Hxxxx_B_Plan_1; Hxxxx_B_Plan_2, etc. Duplication can be minimized by following the instructions in Section 2 and IV.3.
This particular institutional SNP type is numbered.(insert actual contract number and plan number Hxxxx_B_Plan_x)
Type of Institutional SNP
NOTE to Applicant: Review Attachment C, Ensuring Delivery of Institutional SNP Model of Care, which clarifies the requirements the applicant must meet when offering an institutional SNP, particularly concerning the contractual arrangement between the applicant and a long term care (LTC) facility, and the preparedness of the applicant to provide assessment and services in accordance with the SNP Model of Care if the beneficiary moves to a new residence.
Applicant must review and sign attestation in Attachment D.
Identify what institutional population will be targeted by this SNP:
Institutionalized individuals residing in a long term care facility.
Individuals that reside in specific assisted living facilities (ALF) but requiring an institutional level of care
NOTE to applicant: Refer to Attachment C, Policy clarification # 3, for discussion of targeting beneficiaries who reside in ALFs, etc.
Individuals living in the community but requiring an institutional level of care.
A combination of the above populations (Check all that apply).
Identifying Institutionalized Beneficiaries
Provide the procedure the applicant will utilize to verify that the enrollee meets the definition of institutionalized for enrollees residing in a long term care facility.
Provide a copy of the assessment tool the applicant will utilize to determine eligibility.
Describe how the assessment tool will be utilized to determine if the enrollee meets the definition of institutionalized contained in Section 3 of this solicitation. Indicate who will perform the level of care assessment
NOTE to applicant: The applicant must use a CMS approved assessment tool to determine if a potential enrollee meets the definition of institutionalized as defined in Section 3. The Minimum Data Set (MDS) form is an acceptable assessment tool for determining institutional status and may be utilized. The applicant must verify an individual’s eligibility prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of institutional status.
Identifying Beneficiaries Living in the Community but Requiring an Institutional Level of Care
If the applicant intends to limit eligibility to beneficiaries who reside or agree to reside in certain Assisted Living Facilities (ALF), list these facilities.
Describe and provide documentation as to how the applicant will utilize the State assessment tool to determine if an individual meets nursing home level of care. Indicate who will perform the level of care assessment (e.g. State personnel, applicant’s clinical staff).
NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of institutional status. The applicant must use the State assessment tool to determine if a potential enrollee requires a nursing home level of care.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dual eligible population. If the applicant does not have a Medicaid contract proceed to Section B.3.d.
Describe the population(s) the applicant serves under the applicant’s existing Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for the dually eligible institutionalized population enrolled in the SNP.
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries enrolled in the applicant’s institutional SNP with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name, phone number, e-mail address and mailing address (contact information) of the applicant’s contact person at the State Medicaid agency. If the proposed SNP serves more than one State, provide the contact information for each State.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Please indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If applicant selected exclusive, then proceed to Section B. 5.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section 3., propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries not part of the target population (e.g. spouses who may be institutionalized).
State the percentage of the projected enrollment that would constitute the target population.
State the data sources and analytic methods utilized by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
The applicant can submit a SNP proposal in only counties approved or pending approval in the MA contract. The SNP service area can be a subset of the county level approved MA service area. The SNP service area cannot be a subset below the county level approved MA service area. If the approved MA service area is for selected zip codes of a county, the SNP service area must be equal to all the zip codes approved for the MA service area for the county. An exception is a SNP which includes a Medicaid contract for a geographic smaller area than a county.
Complete a separate Attachment B for each SNP proposal. List the State(s) and County(ies) to be served by the SNP proposal. If the SNP proposal will serve all counties in the State, then Attachment B can list “All Counties” instead of listing the individual counties.
SNP
Model of Care
NOTE to applicant:
Refer to the definition of Model of Care
in Section 3. (Clinical expertise required of the Model of Care is
elicited under the provider network Section B.7.).
Description of Model
of Care for the
Institutional
Setting
NOTE to applicant:
If this SNP is not
targeting institutional status beneficiaries residing in a LTC
setting then proceed to Section B.6.b.
List
the goals and objectives of the Model of Care that will drive
service delivery under this institutional eligible SNP. Address
the goals and objectives specific to each of the following:
frail/disabled beneficiaries, beneficiaries with multiple chronic
illnesses and beneficiaries at the end of life.
Describe
how the Model of Care will be implemented in the setting as
defined in B.2.c., specifically the approach to patient
assessment, as well as the organization, coordination, and
delivery of Medicare (and other) services.
Describe
the specific organization of staff (e.g. LTC staff, employees,
nurse practitioners, case managers) who interact with
institutionalized individuals to provide the specialized services
available under the Model of Care.
Describe
the key roles and interactions between the SNP and LTC facility
personnel for the Model of Care to perform as planned. List the
key services provided by the SNP, and key services provided by
the LTC facility. Describe lines of communication and
accountability between the SNP and LTC facility.
Describe
the specific steps the SNP takes (e.g., written protocols and
training) to ensure that the LTC facility personnel understand
how the Model of Care works and how to function in accordance
with that Model of Care.
State
how this Model of Care will identify and meet the needs of
institutionalized beneficiaries.
List
and explain extra benefits and services that will be provided to
meet the needs of institutionalized beneficiaries.
State
what specific processes and outcome measures the applicant will
use to measure performance of the Model of Care for dual eligible
beneficiaries. (See Attachment E).
Description of Model
of Care for
Beneficiaries
Living in the Community but Requiring an
Institutional Level of Care
NOTE to applicant: If
this SNP is not targeting beneficiaries living in
the community but requiring an institutional level of care, then
proceed to Section B.6.c.
List the goals and objectives of the Model of Care that
will drive service delivery under this institutional SNP.
Address the goals and objectives specific to each of the
following: frail/disabled beneficiaries, beneficiaries with
multiple chronic illnesses and beneficiaries at the end of life.
Describe how the Model of Care will be implemented in the
community setting as defined in B.2.b. and B.2.d.1., specifically
the approach to patient assessment, as well as the organization,
coordination, and delivery of Medicare (and other) services.
Describe the specific organization of staff (e.g.
employees, ALF staff, community service workers, nurse
practitioners, case managers) who interact with beneficiaries
living in the community but requiring an institutional level of
care to provide the specialized services available under the
Model of Care.
Describe the key interfaces between the SNP and ALF staff
and community service workers for the Model of Care to perform as
planned. List the key services provided by the SNP, and key
services provided by the ALF staff and community service workers.
Describe lines of communication and accountability between the
SNP and ALF staff and community service workers.
Describe the specific steps the SNP takes (e.g., written
protocols and training) to ensure that the ALF staff and
community service workers understand how the Model of Care works
and how to function in accordance with that Model of Care.
State how this Model of Care will identify and meet the
needs of beneficiaries living in the community but requiring an
institutional level of care.
List
and explain extra benefits and services that will be provided to
meet the needs of beneficiaries living in the community but
requiring an institutional level of care.
State
what specific processes and outcome measures the applicant will
use to measure performance of the Model of Care for beneficiaries
living in the community but requiring an institutional level of
care. (See Attachment E).
Meeting
the Needs of Frail/Disabled Enrollees
Provide
the applicant’s definition of a frail enrollee
either using one of the definitions in Section 3
or something similar.
State whether the applicant’s Model of Care
addresses the needs of frail beneficiaries and/or the needs of
enrollees with a disability.
If serving enrollees with disabilities, specify the types
of disabilities the applicant will address through the SNP.
NOTE to applicant: The
response must include at least one of these categories (frail
enrollees, enrollees with disabilities or both)
Address how the Model of Care will identify and meet the
needs of frail/disabled beneficiaries as defined in B.6.c.1.,
B.6.c.2. and B.6.c.3.
List and
explain extra
benefits and services that will
be provided to meet the needs of frail/disabled
beneficiaries as defined in B.6.c.1., B.6.c.2. and B.6.c.3.
State what specific
process and outcome measures the plan use to measure performance
of the Model of Care
for frail/disabled beneficiaries. (see Attachment
E).
Meeting the Needs of
Enrollees with Multiple Chronic Illnesses
Address how the Model of Care will identify and meet the
needs of beneficiaries with multiple chronic illnesses.
List and
explain extra
benefits and services that will
be provided to meet the needs of individuals with multiple
chronic illnesses.
State
what specific
process and outcome measures the plan will
use to measure performance of the Model of Care
for beneficiaries with multiple chronic illnesses. (See
Attachment E).
Meeting
the Needs of Enrollees that are at the End
of Life
Address how the Model of Care will identify and meet the
needs of beneficiaries at the end of life.
List and
explain extra
benefits and services that will
be provided to meet the needs of individuals at
the end of life.
State what
specific process and outcome measures the plan
will use to measure
performance of the Model of Care for beneficiaries
at the end of life.
(See Attachment E).
Provider Network
State whether the SNP provider and pharmacy networks (if
any) are different from the networks for the applicant’s
other Medicare coordinated care plans (CCP) in the same service
area under this contract.
Using the Model of Care defined in Section 3 as a guide,
specifically describe
the pertinent clinical
expertise the applicant will use to
meet the special needs of the institutional
population.
Also address the pertinent clinical expertise the
applicant believes are necessary to meet the needs of
frail/disabled beneficiaries, beneficiaries with multiple chronic
illnesses, and beneficiaries at the end of life.
If the network does not include sufficient specialists to
meet the special needs of the target population, describe how
access to non-contracted specialists will be arranged.
Specifically, describe the policies and procedures that will be
followed to make sure enrollees have meaningful access
to all necessary providers.
NOTE to applicant: Although
the applicant is required to respond to
the questions
in the SNP proposal regarding the provider network,
separate
HSD tables are not required unless requested by
CMS.
Long Term Care Facilities
List in “Attachment I – Long Term Care
Facilities” all of the applicant’s long term care
facilities contracted to serve the institutional population under
this SNP Model of Care.
Submit a copy
of the contract the applicant will utilize when contracting with
a long-term care facility. In
addition to the terms listed in the Medicare Advantage Managed
Care Manual, Chapter 11, Section 100.4, the applicant
must adequately
address the following, either in the contract with the long term
care provider or in provider materials including, but not limited
to, written policies and procedures and provider manuals. If the
information is addressed in the provider materials, then each
element listed below must be referenced in the contract in a
meaningful way referring the facility to the particular part of
provider materials where the details concerning the element can
be found.
Facilities in a chain organization that are
contracted to deliver the SNP Model of Care
- If the
applicant’s contract is with a chain organization, the
chain organization and the applicant agree to a
list of those facilities that
are included to deliver the SNP Model of Care.
Facilities providing access to SNP clinical Staff
- The facility agrees to provide appropriate access
to
the applicant’s SNP
clinical staff including physicians, nurses, nurse practitioners
and care
coordinators, to the SNP beneficiaries residing in the
applicant’s contracted facilities
in accordance with the SNP protocols for operation.
Providing protocols for the SNP Model of Care
- The applicant agrees to provide protocols
to the facility for
serving the beneficiaries enrolled in the SNP in
accordance with the SNP Model of Care. These protocols must be
referenced in the contract.
Delineation of services provided by the SNP staff
and the LTC facilities under the SNP Model of Care
- A
delineation of the specific services provided by the applicant’s
SNP staff and the
facility staff to the SNP enrollees in accordance with the
protocols and payment for the services provided by the facility.
Training plan for LTC
facility staff to understand SNP Model
of Care
- A training plan to ensure
that the LTC facility staff understand their responsibilities in
accordance with the SNP Model of Care,
protocols and contract. If the training plan is a
separate document it should be referenced in the contract.
Procedures for facility to maintain a list of
credentialed SNP clinical staff
- Procedures that ensure
cooperation between the SNP and facility in maintaining a list of
credentialed SNP clinical staff.
Contract Year for SNP
- Contract
must include the full
CMS contract cycle which begins on
January 1st
and ends
on December 31st.
The applicant may also contract with additional LTC facilities
throughout the CMS contract cycle.
Grounds for early termination and transition plan
for beneficiaries enrolled in the SNP
- Termination
clause must clearly state any grounds for early termination of
the contract. The contract must include
a clear plan for transitioning the beneficiary should the
applicant’s contract with the long term care facility
terminate.
Individuals
with end stage renal disease
State whether the applicant intend to
enroll beneficiaries with end stage renal disease
(ESRD) in its institutional SNP If
no, proceed to Section B.10.
If the applicant intends to enroll individuals with ESRD
in its institutional SNP,
please describe how the organization will serve
the unique needs of this population.
List the contracted dialysis facilities in “Attachment
G –Dialysis Facilities”.
List the contracted transplant facilities in “Attachment
H – Transplant Facilities”.
List any additional services that will be provided to
beneficiaries with ESRD.
Describe the role of the care coordinator in the
assessment and delivery of services needed by beneficiaries with
ESRD.
NOTE to applicant:
If a SNP is approved to serve ESRD beneficiaries, the exceptions
authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver
pursuant to 42 CFR
422.52 (c) will be provided to the applicant. The
signed waiver will be attached to the MA contract. If this is a
MA organization that is adding a SNP, the waiver will be sent
following final approval and the waiver must be signed and
returned within 10 calendar days. .
Further, the
applicant may accept a copy of the CMS form 2728,
“ESRD Medical
Evidence
Report
Medicare
Entitlement
and/or Patient
Registration”
as
verification of ESRD status prior to enrollment,
B.10 Targeting an Alternative
Institutional Population
to the One Described Above
NOTE to applicant:
If the applicant also intends to target an alternative institutional
population to the one
described above, then duplicate the institutional
section of the template (Section B) here
and continue with Hxxxx_B_ Plan
_2, etc.
If the applicant is not intending to propose any additional
institutional
SNPS, then proceed to Section C.
SEVERE OR DISABLING CHRONIC CONDITION SNP TYPE
Number Assignment for each Severe or Disabling Chronic Condition SNP Type
State whether the applicant is proposing a SNP to serve individuals with severe or disabling chronic conditions
State how many different severe or disabling chronic condition SNP types are being proposed.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in C.1.b. Duplication can be minimized by following the instructions in Section 2 and Section 4.3. Consecutively label each severe or disabling chronic condition SNP type as Hxxxx_C_Plan_1; Hxxxx_C_Plan_2, etc.
This particular severe or disabling chronic condition SNP type is numbered… (Insert actual contract number and plan number)
Type of Severe or Disabling Chronic Condition SNP
List the disease(s) the applicant intends to target in this severe or disabling chronic condition SNP. Refer to the chronic conditions listed in Attachment K.
Provide the procedure the applicant will utilize to verify eligibility of the severe or disabling chronic condition(s) for enrollment in the SNP.
NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used to determine if a potential enrollee meets the eligibility requirement for a chronic condition SNP. The applicant may obtain a letter from the potential enrollee's physician with verification if the enrollee’s condition or request authorization from the beneficiary or his/her representative, consistent with HIPAA, to contact the enrollee’s physician to verify eligibility for the SNP. In addition, an applicant may be approved to use a Pre-enrollment Qualification Assessment tool as an alternative to the existing pre-enrollment verification processes. The applicant must review Attachment J and follow all of the instructions contained in Attachment J if the applicant is seeking approval to utilize the Pre-enrollment Qualification Assessment tool to verify eligibility in a chronic SNP. A request to utilize this alternative chronic SNP verification process must be submitted as part of the applicant’s SNP proposal.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dually eligible population. If the applicant does not have a Medicaid contract, proceed to section C. 3.d.
Describe the population(s) the applicant serves under the applicant’s existing Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for dually eligible beneficiaries with the targeted severe or disabling chronic condition that are enrolled in the applicant’s SNP.
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries enrolled in the chronic SNP with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name, phone number, e-mail address and mailing address (contact information) of the applicant’s contact person at the State Medicaid agency. If the proposed SNP serves more than one State, provide the contact information for each State.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If applicant selected exclusive, then proceed to Section C.5.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section 3, propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries not part of the target population (e.g. spouses of beneficiary with chronic condition).
State what percentage of the projected enrollment would be the target population.
State what data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
The applicant can submit a SNP proposal in only counties approved or pending approval in the MA contract. The SNP service area can be a subset of the county level approved MA service area. The SNP service area cannot be a subset below the county level approved MA service area. If the approved MA service area is for selected zip codes of a county, the SNP service area must be equal to all the zip codes approved for the MA service area for the county. An exception is a SNP which includes a Medicaid contract for a geographic smaller area than a county.
Complete a separate Attachment B for each SNP proposal. List the State(s) and County (ies) to be served by the SNP proposal. If the SNP proposal will serve all counties in the State, then Attachment B can list “All Counties” instead of listing the individual counties.
SNP
Model of Care
NOTE to applicant:
Refer to the definition of Model of Care
in Section 3. (Clinical expertise required of the Model of Care is
elicited under the provider network Section C.7.)
List the
goals and objectives of the Model of Care that will drive service
delivery under this SNP serving individuals with severe or
disabling chronic conditions. Address the goals and objectives
specific to each of the following: frail/disabled beneficiaries,
beneficiaries with multiple chronic illnesses, and beneficiaries
at the end of life.
Describe
the specific organization of staff (e.g. employees, community
service workers, nurse practitioners, case managers) who interact
with individuals with sever or disabling chronic conditions to
provide the specialized services available under the Model of
Care.
Describe
the respective roles of the staff as identified in C.6.b.
Describe
the lines of communication and accountability between the SNP and the
staff.
Describe
the specific steps the SNP takes (e.g. written protocols and
training) to ensure that the staff understands how the Model of Care
works and to function in accordance with the Model of Care.
State
how this Model of Care will identify and meet the needs of
beneficiaries with severe or disabling chronic conditions.
List
and explain extra benefits and services that will be provided to meet
the needs of beneficiaries with severe or disabling chronic
conditions.
State
what specific process and outcome measures the applicant will use to
measure performance of the Model of Care for individuals with severe
or disabling chronic conditions.( See Attachment E)
Meeting
the Needs of Frail/Disabled
Enrollees
Provide the applicant’s definition of a frail enrollee
either using one of the definitions in Section 3 or
something similar.
State whether this Model of Care specifically addresses the needs of
frail beneficiaries, and/or the needs of enrollees with a disability.
If serving enrollees with disabilities specify the types of
disabilities the applicant will address through the SNP.
NOTE
to applicant: The response should address
at least one of these categories (frail enrollees, enrollees with
disabilities or both)
Address how the Model of Care will identify and meet the needs of
frail/disabled beneficiaries as defined in C.6.i.1., C.6.i.2 and
C.6.i.3.
List and explain extra
benefits and services that will
be provided to meet the needs of frail/disabled
beneficiaries as defined in
C.6.i.1., C.6.i.2 and C.6.i.3.
Address what specific
process and outcome measures the plan use to measure performance of
the Model of Care
for frail/disabled beneficiaries. (see Attachment E)
Meeting
the Needs of Enrollees with Multiple Chronic
Illnesses
Address how the Model of Care will identify and meet the needs of
beneficiaries with multiple chronic illnesses.
List and
explain extra benefits
and services that will
be provided to meet the needs of individuals with multiple chronic
illnesses.
Address what specific
process and outcome measures the plan will use
to measure performance of the Model of Care for
beneficiaries with multiple chronic illnesses. (See Attachment E).
Meeting
the Needs of Enrollees that are at the End of
Life
State
how this Model of Care will identify and meet the needs of
beneficiaries who are at the end of life.
List
and explain extra
benefits and services that will
be provided to meet the needs of beneficiaries facing the end of
life.
State
what specific process
and outcome measures the plan will use
to measure performance of the Model of Care for
beneficiaries facing the end of life. (See Attachment E)
Provider Network
State
whether the SNP provider and pharmacy networks are different than the
networks for the applicant’s other Medicare coordinated care
plans (CCP) in the same service area.
Using
the Model of Care described in Section 3 as a guide, describe the
pertinent clinical
expertise that the applicant will use
to meet the special needs of individuals with severe
or disabling conditions served through this SNP. Also address the
pertinent clinical expertise the applicant believes are necessary to
meet the needs of frail/disabled beneficiaries, beneficiaries with
multiple chronic illnesses, and beneficiaries at the end of life.
If
the network does not include sufficient specialists to
fully meet the special needs of the target population,
describe how access to non-contracted specialists will be arranged.
Specifically, describe the policies and procedures that will be
followed to make sure enrollees have meaningful access
to all necessary providers.
NOTE
to applicant: Although
the applicant is required to answer fully the questions
in the SNP proposal regarding the provider network,
separate
HSD tables are not required as part of the SNP
proposal unless requested by CMS.
Individuals
with End
Stage
Renal
Disease
State
whether the applicant intends to
enroll beneficiaries with end stage renal disease
(ESRD) in its chronic SNP. If no, then proceed to Section C.9.
If
the applicant intends to enroll individuals with ESRD
in its severe or disabling chronic condition SNP,
describe how the organization will serve the unique
needs of this population.
List
the contracted dialysis facilities in “Attachment G –Dialysis
Facilities”.
List
the contracted transplant facilities in “Attachment H –
Transplant Facilities”.
List
any additional services that will be provided to beneficiaries with
ESRD.
Describe
the role of the care coordinator in the assessment and delivery of
services needed by beneficiaries with ESRD.
NOTE
to applicant: If a SNP is approved to serve
ESRD beneficiaries, the exceptions authority in 42 CFR
422.50(a)(2)(iii) would apply and a waiver pursuant to 42
CFR 422.52 (c) will be provided to the applicant. The
signed waiver will be attached to the MA contract. If this is a MA
organization that is adding a SNP, the waiver will be sent following
final approval. In both cases the waiver must be signed and returned
within 10 calendar days. Further, the
applicant may accept a copy of the CMS form 2728,
“ESRD Medical
Evidence
Report
Medicare
Entitlement
and/or Patient
Registration”
as
verification of ESRD status prior to enrollment,
C. 9.
Targeting an
Alternative Chronic Disease SNP to
the One Described Above
NOTE
to applicant: If
the applicant also intends to target an alternative population with
a severe or disabling chronic condition to the
one described above, then duplicate the Chronic SNP
section (Section
C) of the template here
and continue with Hxxxx_C_ Plan_
2, etc.
MODEL OF CARE
All SNP applicants, regardless of the proposed type of SNP plan, must complete Section D., Model of Care. Unless otherwise noted, all elements under each topical heading should be addressed.
Goals and objectives
Delineate the goals and objectives that will drive service delivery for the SNP-targeted population.
Explain how the goals and objectives apply to the following vulnerable sub-populations likely to exist within the SNP-targeted population:
frail/disabled beneficiaries
beneficiaries with multiple chronic illnesses
beneficiaries near the end of life
beneficiaries with end-stage renal disease (ESRD) if the applicant intends to enroll them
NOTE to all applicants: In the description of subsequent Model of Care components (D.2. through D.8) and for each SNP type, include a discussion thread that explicitly addresses how the model applies to beneficiaries who are frail/disabled, have multiple chronic illnesses, and/or are near the end of life. You will not be further prompted to continue this thread; however, your application will be evaluated on how your Model of Care incorporates these vulnerable groups.
NOTE to applicants intending to enroll ESRD beneficiaries: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50 (a) (2) (iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is an MA organization that is adding a SNP, the waiver will be sent following final approval and the waiver must be signed and returned within 10 calendar days. Further, the applicant may accept a copy of the CMS form 2728, “ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration” as a verification of ESRD status prior to enrollment.
Comprehensive Risk Assessment
Describe the process for initial and periodic comprehensive health risk assessments addressing each of the following elements. Indicate a time frame for initial assessment that expedites care planning and case management. Specify the risk stratification that will be used to drive the level of benefits and services assigned to beneficiaries in each risk category for the SNP-targeted population.
physical and mental health assessments
activities of daily living (ADLs)
social and physical environment
caregiver availability and capacity (e.g., frail/disabled beneficiary in any SNP plan; beneficiary having dementia in a chronic condition SNP plan; any SNP plan beneficiary assessed as a high risk category)
protocol for initially assessing and transitioning beneficiary from current treatment regimens (e.g., chemotherapy, acute hospitalization, nursing home stay, etc.) into SNP plan provider network
Include the risk assessment tool as a document attachment in the electronic file.
Specialized Provider Network
Describe the mix of healthcare providers and health facilities in the plan’s network that have specialized expertise to deliver services to the SNP-targeted population addressing each of the following elements:
specialty and primary care providers and their care roles within the network (e.g., cardiology consultant for a beneficiary with chronic heart failure in a chronic condition SNP; registered nurse responsible for the immunization schedule of a frail/disabled beneficiary who is institutionalized)
pharmacy network if different from the applicant’s other Medicare coordinated care plans
case managers and their care role (e.g., coordination of benefits for dual eligibles)
acute care and rehabilitation facilities (e.g., hospitalization of a beneficiary with multiple chronic conditions who suffers an acute diabetic emergency; rehabilitation services for the post-stroke beneficiary having residual cognitive and functional deficits in a chronic condition SNP plan)
facilities with specialized services (e.g., dialysis facility for a beneficiary with end-stage renal disease; assisted living facility for beneficiaries living in the community but requiring an institutional level of care)
long-term facilities (e.g., skilled nursing facility for a beneficiary near the end of life)
NOTE to all applicants: Although the applicant is required to respond to the above-listed elements in explaining the provider network, separate HSD tables are not required unless requested by CMS.
NOTE to applicants intending to enroll ESRD beneficiaries: Complete “Attachment G – Dialysis Facilities” and “Attachment H – Transplant Facilities” by listing all contracted dialysis and transplant facilities.
NOTE to applicants intending to implement a SNP plan for institutionalized beneficiaries: Complete “Attachment I – Long Term Care Facilities” by listing all contracted long term care facilities. In addition, submit a copy of the contract the applicant will utilize when contracting with a long-term care facility. Over and above the terms listed in the Medicare Advantage Managed Care Manual, Chapter 11, Section 100.4, the applicant must adequately address the following, either in the contract with the long term care provider or in provider materials including, but not limited to, written policies and procedures and provider manuals. If the information is addressed in the provider materials, then each element listed below must be referenced in the contract in a meaningful way referring the facility to the particular part of provider materials where the details concerning the element can be found.
Facilities in a chain organization that are contracted to deliver the SNP Model of Care
- If the applicant’s contract is with a chain organization, the chain organization and the applicant agree to a list of those facilities that are included to deliver the SNP Model of Care.
Facilities providing access to SNP clinical Staff
- The facility agrees to provide appropriate access to the applicant’s SNP clinical staff including physicians, nurses, nurse practitioners and care coordinators, to the SNP beneficiaries residing in the applicant’s contracted facilities in accordance with the SNP protocols for operation.
Providing protocols for the SNP Model of Care
- The applicant agrees to provide protocols to the facility for serving the beneficiaries enrolled in the SNP in accordance with the SNP Model of Care. These protocols must be referenced in the contract.
Delineation of services provided by the SNP staff and the LTC facilities under the SNP Model of Care
- A delineation of the specific services provided by the applicant’s SNP staff and the facility staff to the SNP enrollees in accordance with the protocols and payment for the services provided by the facility.
Training plan for LTC facility staff to understand SNP Model of Care
- A training plan to ensure that the LTC facility staff understand their responsibilities in accordance with the SNP Model of Care, protocols and contract. If the training plan is a separate document it should be referenced in the contract.
Procedures for facility to maintain a list of credentialed SNP clinical staff
- Procedures that ensure cooperation between the SNP and facility in maintaining a list of credentialed SNP clinical staff.
Contract Year for SNP
- Contract must include the full CMS contract cycle which begins on January 1st and ends on December 31st. The applicant may also contract with additional LTC facilities throughout the CMS contract cycle.
Grounds for early termination and transition plan for beneficiaries enrolled in the SNP
- Termination clause must clearly state any grounds for early termination of the contract. The contract must include a clear plan for transitioning the beneficiary should the applicant’s contract with the long term care facility terminate.
Coordinated Care and Case Management
Describe how the risk assessment stratification will determine the types of benefits and services needed by the beneficiaries in the SNP-targeted population, and how care will be coordinated across the provider network. In addition, explain explicitly how case management will be applied to assure:
coordination of care across healthcare and community settings (e.g., the chronic care SNP beneficiary having a coronary artery stent post-angioplasty, emphysema, and diabetic retinopathy who needs periodic cardiology, pulmonary, and ophthalmology consults within and/or out-of-network)
continuity of care during transitions (e.g., enrollments/disenrollments; changes in a provider network)
involvement of the caregiver in developing and implementing the care plan (e.g., caregiver role in developing advance directives for beneficiaries near the end of life)
Healthcare Delivery System
Describe the delivery of specialized care appropriate to the SNP-targeted population addressing each of the following elements:
use of evidenced-based disease management protocols (e.g., using protocols recommended in the ATP III Cholesterol guidelines, JNC 7 Hypertension guidelines, Asthma, Expert Panel Report 3, or similar evidence-based clinical practice guidelines to manage beneficiaries having multiple chronic conditions)
process for using out-of-network providers when necessary
extra benefits and services that differentiate this model of care from other MA CCP plan types
Communication and Accountability
Describe the system of communication among healthcare providers that assures that specialized needs of the SNP-targeted population will be met and healthcare providers will be accountable for service delivery addressing each the following elements:
communication across the provider network
communication with caregivers
communication with participants that accounts for health literacy levels and cultural issues
communication with federal, state, and community agencies as appropriate (e.g., CMS and state reporting requirements, reportable communicable diseases, etc.)
SNP Training and Competency Assurance
Describe the process for training and assuring competency among the specialized experts needed to deliver focused health services to the SNP-targeted population addressing each of the following elements:
compliance with SNP regulations
knowing and implementing the SNP-specific model of care
knowledge and experience with the SNP-targeted population
procedures for assuring credentials verification and periodic competency review across the provider network
Performance Measurement and Improvement
Describe the process and outcome measures that will be used to measure performance in implementing the model of care for the SNP-targeted population addressing each of the following elements:
specific measures used for data collection
methodology for collection and analysis of data
process for performance improvement based on data analysis
dissemination of analysis results across the provider network
required plan level reporting to CMS and state
inclusion of measures that evaluate the model of care for applicable sub-populations:
frail/disabled beneficiaries
beneficiaries with multiple chronic illnesses
beneficiaries near the end of life
Subsets for Dual Eligible SNPs
Medicare Advantage Organizations (MAO) that offers Dual Eligible SNPs will be able to exclude specific groups of dual eligibles based on the MAO’s coordination efforts with State Medicaid agencies. Requests for dual eligible subsets will be reviewed and approved by CMS on a case by case basis.
To the extent a State Medicaid agency excludes specific groups of dual eligibles from their Medicaid contracts or agreements, those same groups may also be excluded from enrollment in the SNP
For example, if an MAO offering a Dual Eligible SNP has a Medicaid managed care contract with a State Medicaid agency for all dual eligibles except for those who are medically needy with a spend down, the MAO may also exclude those dual eligibles from enrollment in the SNP.
Those dual eligible groups which are included in the SNP request are those in which the MAO offering a SNP coordinates its Medicare related efforts in an integrated way with the State’s Medicaid coverage and administration.
For example, a targeted group could be aged dual eligibles for which the SNP and State provide coordinated care.
MAOs may limit enrollment to dual eligible beneficiaries through a dual eligible SNP without State Medicaid agency coordination (other than to be in compliance with applicable State licensing laws or laws relating to plan solvency), if enrollment is limited to one of the following three categories of dual eligible beneficiaries: 1) all dual eligibles; 2) full benefit dual eligibles or 3) Zero cost sharing duals (QMBs and QMB+++++++ pluses). (Refer to definitions in Section 3).
SNP Service Area
Date Submitted to CMS:
_____________________ |
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County |
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Ensuring Delivery of Institutional SNP Model of Care
The following clarifies CMS expectations concerning the existence of an appropriate SNP Model of Care and enrollment will be limited to settings where it can be ensured that appropriate care can be delivered.
Background
The Medicare Modernization Act (MMA), Section 231, provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dual eligible beneficiaries; and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary.
An institutionalized individual was defined by regulation in 42 CFR 422.2 as an individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care (LTC) facility which is a skilled nursing facility (SNF), nursing facility (NF), intermediate care facility for the mentally retarded (ICF/MR); or inpatient psychiatric facility.
The preamble to the new regulations stated that CMS would also consider an institutional Special Needs Plan (SNP) to serve individuals living in the community but requiring an institutional level of care, although this was not included in the regulatory definition. (Many beneficiaries who would qualify for institutional status in the community reside in some type of assisted living facility (ALF).)
All SNP proposals are required to provide a description of the SNP Model of Care that the Medicare Advantage Organization (MAO) has designed and must implement specifically to serve the special population in the MAO’s SNP. The word “specialized” in the statute clearly contemplates that the SNP product provides for “specialized” benefits that are targeted to meet the needs of the SNP population. Some aspects of the Model of Care concept described in Section 3 of the SNP solicitation, as well as how it would be implemented, will vary depending on the site of care LTC facility or in the community, based on, for example the availability of and need for staff and community services. Refer to the Model of Care definition in Section 3 of the SNP solicitation.
Institutional SNPs can be restricted to enrollment of those individuals residing in long term care facilities or to individuals living in the community , or both can be included under an institutional SNP
Policy Clarification #1
MAOs offering an institutional SNP to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the LTC facility to deliver its SNP Model of Care. The contracted/owned approach provides assurances that beneficiaries will be assessed and receives services as required under the SNP Model of Care. The institutional setting is complex and requires coordination between the SNP and facility providers and administrative staff, which can not be attained without a strong, well articulated MAO/facility relationship. Without a contractual or ownership arrangement, the MAO can not ensure the complex interface will function appropriately and care will be delivered in accordance with the Model of Care. Furthermore, this approach to limiting enrollment to contracted LTC facilities assures the delivery of uniform benefits
Policy Clarification #2
MAO marketing materials and outreach for new enrollment must make clear that enrollment is limited to the CMS approved targeted population and to those beneficiaries who live in, or are willing to move to, contracted LTC facilities. If the MAO’s institutional SNP enrollee changes residence, the MAO must have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence. Appropriate documentation includes that the MAO has a contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care.
Policy Clarification # 3
An institutional SNP serving individuals living in the community but requiring an institutional level of care may restrict access to enrollment to those individuals that reside in, or agree to reside in, a contracted Assisted Living Facility (ALF) as this is necessary in order to ensure uniform delivery of specialized care.
If a community based institutional SNP is limited to specific assisted living facilities, a potential enrollee must either reside or agree to reside in the MAOs contracted ALF to enroll in the SNP.
Proposals for this type of institutional SNP will be reviewed on a case by case basis for approval and the applicant must demonstrate the need for the limitation, including how community resources will be organized and provided.
NOTE to applicant: If consolidating SNP proposals across multiple contracts, include all the contract numbers in this consolidated proposal.
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
(Name of Organization)
(H number)
I attest that in the event the above referenced organization has a CMS approved institutional SNP, the organization will only enroll beneficiaries in the SNP who (1) reside in a Long Term Care (LTC) facility under contract with or owned by the organization offering the SNP to provide services in accordance with the institutional SNP Model of Care approved by CMS, or (2) agree to move to such a facility following enrollment.
I attest that in the event the above referenced organization has a CMS approved institutional SNP to provide services to community dwelling beneficiaries who otherwise meet the institutional status as determined by the State, the SNP will ensure that the necessary arrangements with the community are in place to ensure beneficiaries will be assessed and receive services as specified by the SNP Model of Care.
I attest that if a SNP enrollee changes residence, the SNP will have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence, or disenroll the resident in accordance with CMS enrollment/disenrollment policies and procedures. Appropriate documentation includes that the SNP has a contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care.
___________________________ ____________________________
CEO DATE
___________________________ ____________________________
CFO DATE
Quality Measurement for Special Needs Plans
CMS is currently working on developing a set of standard quality measures tailored to the special need populations served in the SNP program. Those measures are in development and are not yet available. Each applicant that offers or is seeking to offer a SNP should develop internal process and outcome measures that can be used by the organization to determine if the Model of Care is having its intended effect on the targeted SNP population.
An applicant should determine how its organization will record and report these measures for the specific population served by the SNP and how this information will be used to drive quality improvement.
Crosswalk Consolidating Proposals for Dual Eligible SNPs
Applicant’s contracting Name (As provided in HPMS): MAP SNP Example
Date submitted to CMS:_____________________________ |
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Name of the baseline SNP proposal:
|
Number assignment for each dual eligible SNP type |
Type of Dual SNP |
Relationship of SNP product to State Medicaid services in the event of other subsetting |
State contracts information if other subsetting is not being requested by applicant |
Exclusive versus disproportionate percentage population |
Service area to be served by SNP |
SNP Model of Care |
|
Contract # |
Plan # |
A.1 |
A.2 |
A.3 |
A.4 |
A.5 |
A.6 |
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H9999 |
H9999_A_Plan_1 |
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(Example) |
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ATTACHMENT F
Crosswalk Consolidating Proposals for Dual Eligible SNPs
Applicant’s contracting Name (As provided in HPMS): MAP SNP Example
Date submitted to CMS:_____________________________ |
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Number assignment for each institutional SNP type |
Type of institu- tional SNP |
Identifying institu- tionalized benefici- aries |
Identifying beneficiaries living in the community but requiring an institutional level of care |
State contracts infor-mation |
Exclusive versus dispropor-tionate percentage population |
Service area to be served by SNP |
SNP Model of Care |
||
Contract # |
Plan # |
B.1 |
B.2 |
B.2.c |
B.2.d |
B.3 |
B.4 |
B.5 |
D |
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H9999 |
H9999_B_Plan_1 |
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(Example) |
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ATTACHMENT F
Crosswalk Consolidating Proposals for Severe or Disabling Chronic Condition SNPs
Date Submitted to CMS: _________________ |
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Name of the baseline SNP proposal: |
Number assignment for each severe or disabling chronic condition SNP type |
Type of chronic condition SNP |
State contracts information |
Exclusive versus disproportionate percentage population |
Service area to be served by SNP |
SNP Model of Care |
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Contract # |
Plan # |
C.1 |
C.2 |
C.3 |
C.4 |
C.5 |
D |
H9999 |
H9999_C_Plan_1 |
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ATTACHMENT G – Dialysis Facilities Table
Dialysis Facilities
Date Submitted to
CMS: _____________________ Applicant’s
Contracting Name (as provided in HPMS):
___________________________ Contract #/Plan #: H9999_A_Plan _1 (example)___ |
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Name of Dialysis Facilities |
Medicare Provider # |
Facilities Address |
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ATTACHMENT H –Transplant Facilities Table
Transplant Facilities
Date Submitted to
CMS: _____________________ Applicant’s
Contracting Name (as provided in HPMS):
___________________________
Contract #/Plan #: H9999_A_Plan _1 (example)___ |
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Name of Transplant Facilities |
Medicare Provider # |
Facilities Address |
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ATTACHMENT I – Long Term Care Facilities Table
Long Term Care Facilities
Date Submitted to
CMS: _____________________ Applicant’s
Contracting Name (as provided in HPMS):
___________________________
Contract #/Plan #: H9999_B_Plan _1 (example)___ |
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Name of Long Term Care Facilities |
Medicare Provider # |
Facilities Address |
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ATTACHMENT J-Pre-enrollment Verification
Additional Option for Pre-enrollment Verification of Chronic Condition for Chronic Condition Special Needs Plans
This policy provides an additional option for pre-enrollment verification of a chronic condition to determine eligibility for enrollment in a chronic care special needs plan (SNP).
CMS requires that SNPs serving beneficiaries with severe or disabling chronic conditions verify with a provider or the provider’s office that a potential enrollee has the condition for which the chronic care SNP is targeted. SNPs have reported that some providers or their office staff may not be readily accessible to obtain verification in a timely manner.
Therefore, effective May 31, 2007, a Medicare Advantage Organization (MAO) may be approved to use a Pre-enrollment Qualification Assessment tool as an alternative to the existing pre-enrollment verification processes.
CMS will approve the use of a Pre-enrollment Qualification Assessment tool under the following conditions:
1) h The Pre-enrollment Qualification tool provides for each applicable condition a clinically appropriate set of questions relevant to the specific condition(s) that cover the potential enrollee’s past medical history, current signs and/or symptoms, and medication regimen that provides a reliable indicator that the beneficiary has the condition. An example of a pre-qualification questionnaire is attached. CMS is working with the industry to develop model pre-qualification questionnaires that may be used by organizations seeking approval for this alternative verification process.
2) The MAO maintains a record of the results of the Qualification Tool, such as documentation of a phone call. This record must include a date and time that establishes the verification occurred in accordance with the timeframes for completing an MA enrollment request, pursuant to CMS’ Enrollment and Disenrollment Guidance for Medicare Advantage Organizations.
3) The MAO conducts a post-enrollment confirmation of each enrollee’s information and eligibility based on medical information provided by the enrollee’s physician or other provider.
4) The MAO ensures that for all enrollments conducted by an agent or broker, if applicable, any commission or payment associated with that enrollment will be forfeited in the event the condition cannot be confirmed post-enrollment.
5) If the enrollee is accepted into the SNP, but is later determined to not have had the targeted condition, the enrollee will remain in the SNP until the end of the calendar year and will be disenrolled at that time. The MAO must notify the enrollee of this disenrollment by October 1 of each year. The beneficiary will have a Special Enrollment Period (SEP) that begins on October 1 and ends on March 31 of the following year.
6) The MAO tracks the total number enrollees and the number and percent by condition whose post enrollment verification matches the pre-enrollment verification. These data and the supporting documentation will be made available upon request by CMS and will be audited.
7) All information gathered in the pre-enrollment Qualification Tool will be held confidential and in accordance with the privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA). This requirement applies to plan employees as well as the plan’s business associates.
The applicant must submit a request for approval to use a Pre-Enrollment Qualification Assessment Tool (Assessment) as part of the SNP proposal. The Assessment must be tailored to the specific disease(s) to be targeted through the SNP. This attachment contains a number of samples that may be utilized by the applicant in preparing the Assessment.
The request to utilize an Assessment for verification of chronic condition(s) must include an attestation that states the MAO agrees to implement the policy provided in items 1 through 7 above.
Sample Pre-qualification Assessment Tools
Pre-Qualification Assessment for Stroke/TIA
“Yes” to 1 or 2 pre-qualify the candidate. “Yes” to 3 or 4 only require further verification.
Have you ever been told by a doctor or clinic that you have had a blood clot in your brain, a stroke or a near stroke?
Have you had episodes of mental confusion, dizziness, paralysis or loss of consciousness that a doctor has told you were due to poor circulation to the brain?
Have you experienced loss of any of the following:
speech
swallowing
vision,
the use or control of muscles in any part of your body (i.e. loss of control, numbness on one side)
sensation in any part of your body
bowel or bladder control
emotional control
thinking and reasoning ability?
Have you been prescribed or are you taking medication to improve or protect the circulation to the brain such as blood thinners (for example, Coumadin, Lovenox) or platelet clot preventers (for example, aspirin, Plavix, Ticlid or Persantine)?
Pre-Qualification Assessment for Peripheral Vascular Disease
“Yes” to 1, 2, 3 or 4 pre-qualify the candidate. “Yes” to 5 only, requires further verification.
Have your ever been told by a doctor or clinic that you have poor circulation in your arms or legs due to hardening of the arteries or poor veins?
Have you ever had an imaging test (arteriogram, venogram or ultrasound”) that showed decreased circulation in your arms or legs?
Have you ever had an operation to improve the circulation in your arms or legs (not in your heart) such as angioplasty or bypass graft?
Have you ever had a slow healing leg ulcer (sore) or have had an amputation of part of a foot or leg due to poor circulation?
Have you been prescribed or are you taking medication to improve circulation in your arms or legs such as blood thinners (for example, Coumadin, Lovenox) or platelet clot preventers (for example, aspirin, Plavix, Ticlid or Persantine)?
Pre-Qualification Assessment for ESRD
“Yes” to 1, 2 or 3 pre-qualifies beneficiary.
Have you ever been told by a doctor or clinic that you have End Stage Renal Disease/ESRD or kidney failure?
Are you currently on dialysis?
Have you had or are you on a waiting list for an organ transplant? Was/is it for a kidney transplant?
Pre-Qualification
Assessment for Cardiac Events
“Yes”
to any one question 1-8 pre-qualifies the beneficiary. Yes to 9 or
10, only, requires further verification.
Have
you ever had a heart attack?
Have
you ever had cardiac bypass surgery (open heart surgery)?
Have
you ever had an angioplasty or stent in your heart?
Have
you been told by a doctor or clinic that you have heart failure (weak
heart)?
Have
you ever had heart
valve
replacement surgery?
Have
you had a cardiac arrest?
Do
you have a pacemaker and/or defibrillator?
Have
you ever had an operation to get rid (ablation) of a heart
arrhythmia, skipped
or fast heart beats?
Do
you have a heart arrhythmia (funny rhythm) which requires you to take
medication?
Have
you ever experienced chest pain
or
severe pressure
(angina) and was told by your doctor or clinic it was heart related?
Pre-Qualification Assessment for Chronic Heart Failure
“Yes” to question 1 or questions 2 and 3 pre-qualifies the candidate. Yes to question 2 or 3 only requires further verification.
Have you ever been told by a doctor or clinic that you have heart failure (weak heart)?
Have you had problems with fluid in your lungs and swelling in your legs in the past, accompanied by shortness of breath, due to a heart problem?
During the past 12 months, have you been counseled or educated about weighing yourself daily due to a heart problem?
Pre-Qualification Assessment for Coronary Artery Disease
“Yes” to any one of questions 1-5, pre-qualifies candidates. Yes to 6 only requires further verification.
Have you ever been told by a doctor or clinic that you have Coronary Artery Disease?
Have you ever had a heart attack?
Have you ever had an admission to the hospital for angina (chest pain)?
Have you ever had cardiac bypass surgery (open heart surgery)?
Have you ever had an angioplasty or stent in your heart?
Have you ever experienced chest pain (angina) and was told by your doctor it was heart related?
Pre-Qualification Assessment for COPD
“Yes” to 1, 2, 3 or 4 pre-qualify the candidate.
Have you ever been told by a doctor or clinic that you have COPD (chronic), chronic Bronchitis, emphysema and/or chronic asthma?
Do you suffer from chronic coughing or shortness of breath for which you have been prescribed or are taking medicine?
Have you smoked for 20 years or more and, if so, do you have a chronic cough or shortness of breath?
Have you been prescribed or are you taking a medication or oxygen for any chronic lung disease such as COPD (chronic obstructive pulmonary disease), chronic Bronchitis, emphysema and/or chronic asthma?
Pre-Qualification Assessment for Hypertension
“Yes” to 1 and pre-qualify the candidate.
Have you been told by a doctor or clinic you have hypertension or high blood pressure?
Have you been prescribed or are you taking medication for high blood pressure?
Pre-Qualification Assessment for Depression
“Yes” to 1, 2 or 3 pre-qualifies candidate
Have you been told by a doctor or clinic that you have depression?
Have you been treated for depression with any of the following?
With medication
With therapy
With ECT (shock treatments)
Have you ever been hospitalized for depression?
Pre-Qualification Assessment for Dementia
“Yes” to1 or 2 pre-qualifies the candidate. “Yes” to 3 only requires further verification...
Does the applicant have memory loss that interferes with daily activities?
Has the applicant been told by a doctor or clinic that they have any form of dementia or Alzheimer’s disease?
Is the applicant taking either Namenda or Aricept for Alzheimer’s disease?
Pre-Qualification Assessment for Diabetes
“Yes” to 1 or 2 pre-qualifies the candidate.
Have you ever been told by a doctor or clinic that you have diabetes (too much sugar in the blood or urine)?
Have you been prescribed or are you taking insulin or an oral medication that is supposed to lower the sugar in your blood?
Pre-Qualification Assessment for Chronic Renal Disease
“Yes” to 1, 2, 3 or 4 pre-qualify the candidate. “Yes” to 5, 6 or 7 only require further verification.
Have you ever been told by a doctor or clinic you had chronic renal disease?
Have you ever been told by a doctor or clinic your kidney function is abnormal?
Have you ever been told by a doctor or clinic you had a high creatinine level?
Have you been told by a doctor of a problem with your kidneys other than stones or infection?
Have you ever had to collect your urine for 24 hours to measure your kidney function?
Have you been told by a doctor or clinic that you had protein or blood in your urine?
Have you been told by a doctor or clinic to decrease protein in your diet?
List of Severe or Disabling Chronic Conditions – 2008-2009 HPMS Crosswalk
2008 Chronic Condition List |
2009 Chronic Condition List |
Chronic cardiomyopathy |
CVD: Chronic Heart Failure |
Coronary artery disease |
CVD: Coronary Artery Disease |
Hypertension |
CVD: Hypetension |
Asthma |
COPD: Asthma |
Chronic obstructive pulmonary disease |
COPD: Asthma |
Chronic obstructive pulmonary disease |
COPD: Chronic bronchitis |
Chronic obstructive pulmonary disease |
COPD: Emphysema |
Diabetes |
Endocrine/Metabolic: Diabetes |
Hypercholesteremia |
Endocrine/Metabolic: Dyslipidemia |
Obesity |
Endocrine/Metabolic: Obesity |
HIV |
Immune Disorders: HIV infection |
Arthritis |
Joint Disorders: Osteoarthritis |
Ischemic Stroke |
Neurologic Disorders: Ischemic stroke |
Dementia |
Neurologic Disorders: Dementia |
Chronic kidney disease |
Renal Disorders: Chronic renal failure |
Renal failure |
Renal Disorders: Chronic renal failure |
Renal failure (pre-End Stage Renal Disease) |
Renal Disorders: Chronic renal failure |
End-stage renal disease |
Renal Disorders: End-stage renal disease (ESRD) |
Post-kidney transplant |
Status-post Organ Transplantation |
Other |
Other |
Cardiovascular disease |
CVD: Cardiac Arrhythmia |
Cardiovascular disease |
CVD: Chronic Heart Failure |
Cardiovascular disease |
CVD: Coronary Artery Disease |
Cardiovascular disease |
CVD: Hypetension |
Cardiovascular disease |
CVD: Peripheral Vascular Disease |
Heart Disease |
CVD: Cardiac Arrhythmia |
Heart Disease |
CVD: Chronic Heart Failure |
Heart Disease |
CVD: Coronary Artery Disease |
Heart Disease |
CVD: Hypetension |
Heart Disease |
CVD: Peripheral Vascular Disease |
Mental illness |
Psychiatric Disorders: Alcoholism |
Mental illness |
Psychiatric Disorders: Bipolar disorder |
Mental illness |
Psychiatric Disorders: Drug dependency |
Mental illness |
Psychiatric Disorders: Major depression |
Mental illness |
Psychiatric Disorders: Schizophrenia |
Neurological condition |
Neurologic Disorders: Dementia |
Neurological condition |
Neurologic Disorders: Hemorrhagic stroke |
Neurological condition |
Neurologic Disorders: Ischemic stroke |
Psychiatric disorders |
Psychiatric Disorders: Alcoholism |
Psychiatric disorders |
Psychiatric Disorders: Bipolar disorder |
Psychiatric disorders |
Psychiatric Disorders: Drug dependency |
Psychiatric disorders |
Psychiatric Disorders: Major depression |
Psychiatric disorders |
Psychiatric Disorders: Schizophrenia |
|
Key |
|
CVD is cardiovascular disease. |
|
COPD is chronic obstructive pulmonary disease. |
|
New |
|
Immune Disorders: Rheumatoid Arthritis |
|
Liver Disease: Chronic liver failure |
|
Liver Disease: End-stage liver disease (ESLD) |
PART 5 INSTRUCTIONS FOR COMPLETING CMS FORMS
2.1. Form and Table Management
Application forms and tables associated with the applications are available in separate Microsoft Word or Excel files that are available at http://www.cms.hhs.gov/MedicareAdvantageApps/. Microsoft Word files located on the CMS web site are posted in a .zip format.
Most tables require that a separate table be submitted for each area/region/county that an applicant is requesting, by Medicare geographic area. If copies of a table are needed, create multiple blank tables within the same file, being sure to place a hard page break between each table. Save the entire file, now containing two or more tables, with the original file name.
Please note that all documents submitted to HPMS with the application must include file names as specified in Part 6.
2.2 Instructions for CMS Insurance Coverage Table
Instructions
Complete the table by inserting the amount of insurance coverage or other arrangements the applicant has for major types of loss and liability and place a hard copy in the Documents section of the application.
Provide in HPMS, a completed copy of this table in PDF format.
Column Explanations:
Type - Identifies the various types of insurance.
Carrier - Enter the name of the insurance carrier for each insurance type identified by the Applicant.
Entity covered - Enter the name of the entity (organization) that is covered by this insurance.
Description: Deductibles, Co-insurance, Minimum & Maximum Benefits
Premiums - Enter the amount of the premiums.
Period Policies are in effect - Enter the periods that the policies are in effect.
Other Arrangements to Cover These Risks - Enter any other insurance arrangements to cover the Applicant’s risks.
2.3. Instructions for CMS State Certification Form
The applicant should complete items 1 – 3 and then forward the form to the appropriate State Agency Official for completion of items 4 – 7. Upon completion of items 4 – 7, the State agency Official will return the form to the applicant. The applicant must provide in HPMS a copy of this executed form using a PDF format.
All questions must be fully answered. Sufficient space has been provided, however, if additional space is required; please add pages to provide a more detailed response. Additional information can be provided if the Applicant feels it will further clarify the response.
The State Certification form demonstrates that the contract being sought by the applicant with CMS is within the scope of the license granted by the appropriate State regulatory agency and is authorized to bear financial risk.
Items 1 - 3 (to be completed by the Applicant):
1. List the name and complete address of the organization that will enter into the MA contract with CMS.
2. The Applicant should list the type of license (if any) currently being held in the State where an MA contract is being sought.
3. Applicants must specify the type of MA contract being requested from CMS. CMS wants to verify that any MA plans being offered by the MA organization in the State meet State licensure and solvency requirements applicable to a Federal health plan.
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.
Items 4 - 7 (to be completed by State Official):
4. List the reviewer’s pertinent information in case CMS needs to communicate with the individual conducting the review at the State level.
5. Some States require several departments/agencies to review licensure requests. CMS wants to know about other departments/agencies involved in such review/approval.
6. Check the appropriate box to indicate whether the applicant meets State financial solvency requirements.
7. Indicate State Agency or Division, including contact name and complete address, which is responsible for assessing whether the applicant meets State financial solvency requirements.
State Certification Section: Enter the following information:
Name of the Applicant (organization)
State in which the Applicant is licensed
Name of the certifying State Agency
Signature of State Official
Title of State Official
Date of State Certification
2.4. Instructions for CMS Provider Arrangements by County Table
Instructions:
Provide in HPMS, a separate table for each county, partial county, or delivery system.
Column Explanations:
Category - Staff/Group/ IPA/PHO/Direct:
Member Physicians - Licensed Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (D.O.) who are members and/or employees of the entity that contracts with the MA organization.
Member Non-Physicians - Midwives, nurse practitioners, or chiropractors, etc., who are members and/or employees of the entity that contracts with the MA organization.
Non-Member Physicians - Licensed M.D. and D.O. who are contracted and/or subcontracted to provide services on behalf of the entity but are not members and/or employees of the entity.
Non-Member, Non-Physician - Mid-wives, nurse practitioners, or chiropractors, etc., who are subcontracted to provide services to the entity but are not members and/or employees of the entity.
Direct Contract HMO-Physicians - Licensed M.D. and D.O. who have entered into a direct contract with the HMO.
Type of Contract and/or Agreement – Insert number of contracts, or Letter of Agreements (LOA).
Note: Letters of intent, Memorandums of Understanding and Memorandums of Agreement are not acceptable. CMS will accept any legally binding written arrangement.
Number of Contracts and/or Agreements - List the total number of signed contracts and/or agreements.
Automatic Renewal of Contracts and/or Agreements – Insert number of contracts/and or Agreements that are automatically renewed.
Date Executed - Enter the date or date range (in which all contracts and/or agreements were finalized for the particular category.
Contract and/or Agreement Template name - List the template name (i.e., Template A or Templates A- C) for each category.
2.5. Instructions for CMS Provider Participation Contracts and/or Agreements Matrix
This matrix should be completed by MA applicants and should be use to reflect the applicants first tier and downstream contracts and/or agreements.
Instructions:
Provide in HPMS using a PDF format, a separate matrix for each county or partial county.
Enter name of the provider(s)/group(s) or entity that the MA organization contracts with to provide services to Medicare enrollees. Each matrix will need to be filled out for all first tier and downstream providers.
Designate if provider is first tier contracted provider with a "(1)" next to the name of that provider(s)/group(s) or other entity.
Designate downstream contracted provider(s), group, or other entity with a "(DS)".
Under each column list the page number where the provision that meets the regulatory requirement can be found in each of the contracts and/or agreements templates for that particular provider(s), group(s) and other contracted entities.
Note: This matrix contains a brief description of MA regulatory requirements; please refer to full regulatory citations for an appropriate response.
2.6. Instructions for CMS Administrative/Management Delegated Contracting or Arrangement Matrix
This matrix should be completed by network model MA applicants and should be use to reflect the applicants first tier and downstream contracts and/or agreements.
Instructions:
Enter name of entity or entities that the MA applicant has contracted with to provide administrative services to Medicare enrollees
Note: MSA applicants will enter the name of the entity that the applicant has arranged to offer MA MSA accounts in accordance with §1853(e)(2) of the Act.
Matrix will need to be completed for the entire administrative first tier and downstream contracted entities that will be providing administrative services to the MA applicants.
Designate if the contracted entity is a first tier administrative provider with a "(1) next to the name of the provider(s), group or other entity.
Designate any downstream contracted entities for administrative services with "(DS)" next to the name of the entity.
Under each column list the page number where the regulation can be found in each of the administrative services contracts and/or agreements for that particular contracted entity.
Note: Matrix contains a brief description of MA regulatory requirements; please refer to full regulatory citations for an appropriate response.
2.7. General Instructions for CMS HSD Tables 1, 2, 2a, 3, 3a, 4, 5
(Not required for non-network PFFS)
These tables should be completed by contracted-network MA applicants, excluding RPPO applicants.
Instructions:
If an MA applicant has a network exclusive to a particular plan, the applicant must provide in HPMS four separate HSD tables for each plan.
The applicant must list the plan or plans name to which a table applies at the top of each tables. If the table applies to all plans, state “All”.
Enter the date that the tables were constructed next to “date prepared”. The tables should reflect the applicants fully executed contracted network providers and facilities that are in place on of the date of submission..
Note: For CMS purposes, contracts are considered fully executed when both parties have signed.
If a type of provider or facility is not available in a county but the pattern of care is to obtain those medical services from another county listed on an HSD table, the applicant must
Provide in HPMS a narrative of this exception/these exceptions in a PDF file and list the providers in the HSD tables. This narrative should be separated by county and then by HSD table, within each county.
In the rarity that non-contracted providers must be used to provide services to members, applicant must explain within the PDF file how the applicant will ensure that members are not balance-billed for these services.
Applicant must provide these tables in HPMS as Excel documents.
NOTE: RPPO applicants are not required to complete HSD tables but should follow instructions in Section 2 of this application.
2.7.1 Table: HSD-1: County/Delivery System Summary of Providers by Specialty
Instructions:
Providers should be counted only once per county on this table even if the provider has more than one location in a county.
If the applicant uses a subnetwork or has multiple delivery systems within the county/service area, the applicant must complete a separate HSD 1 table for each delivery system. Each HSD 1 table should be representative of the aggregate numbers of providers for the delivery system being described.
If there are other specialties that are not listed, applicant should add lines under "vascular surgery" to cover these specialists.
Applicant must arrange all entries alphabetically by county. Note: Please do not change provider specialty order as listed on HSD-1.
Column Explanations:
Specialty - Self-explanatory-
Note: For radiology, chiropractic, and podiatry list only those providers who are contracted directly with the MAO or downstream entity.
Available Medicare Participating Providers in County-List the number of Medicare participating providers located in the county. Information can be obtained from the Medicare Carriers.
Medicare Provider Breakdown - List the number of contracted providers by type of contract (direct arrangement or downstream arrangement).
Medicare Provider Breakdown - List the number of contracted providers by type of contract (direct arrangement or downstream arrangement).
Total # of Providers - Add up the total number of providers per specialty listed in columns 2 & 3.
May Providers Serve as PCPs? - Enter "Y" if providers may serve as a member's Primary Care Physician. Enter "N" if providers may not serve as a member's Primary Care Physician.
Total # of PCPs Accepting New Patients - If "Y" was entered in column 5, list the total number of providers who are accepting new Medicare patients. New patients are defined as patients who were not previously seen by the physician. If "N" was entered in column 5, please leave the cell blank.
Total # of PCPs Accepting Only Established Patients - If "Y" was entered in column 5, list the total number of providers who are accepting only established patients. Established patients are defined as patients who are already patients of the physician's practice, either under original Medicare, another Medicare managed care organization, or through an age-in arrangement. If "N" was entered in column 5, please leave cell blank.
County - County in which the provider is located.
2.7.2 Table: HSD-2: Provider List - List of Physicians and Other Practitioners by County
Instructions:
Applicant must arrange providers alphabetically by county, then alphabetically by specialty, and finally numerically by zip code.
If a provider sees patients at more than one location, list each location separately.
All providers that compose the total counts on HSD-1 must be listed on HSD-2.
Column Explanations:
Name of Physician—Self Explanatory. Please include chiropractors and podiatrists and Mid-Level Practitioner nurse practitioners and physician assistants.
Specialty - Self-explanatory.
Contract Type - Indicate type of contract with provider. D=Direct and W=Downstream.
Step 4-8
Service Address - Specify the address (street, city, state, zip code, county) where the provider serves patients. If a provider sees patients at more than one location, list each location separately.
Provider Previously Listed? - Enter "Y" if the same provider is previously listed in the rows above. Enter "N" if a provider is not previously listed in the rows above (e.g., the first time a provider listed on the worksheet, a "N" should be entered.)
Contracted Hospital Where Privileged - Identify one contracted hospital in the service area where the provider has admitting privileges, other than courtesy privileges. If the provider does not have admitting privileges, please leave cell blank.
Will Provider Serve as PCP? - Enter "Y" if provider will serve as a member's Primary Care Physician. Enter "N" if provider will not serve as a member's Primary Care Physician.
If PCP, Accepts New Patients? - If "Y" was entered in column 11, indicate if provider accepts new patients by entering a "Y" or "N" response. If "N" was entered in column 11, please leave cell blank.
If PCP, Accepts Only Established Patients? - If "Y" was entered in column 11, indicate if provider accepts only established patients by entering a "Y" or "N" response. If "N" was entered in column 11, please leave cell blank.
Does MCO Delegate Credentialing? - Enter "Y" if the applicant delegates the credentialing of the physician. Enter "N" if the applicant does not delegate credentialing of the physician. If credentialing is not required, please leave cell blank.
If Credentialing is Delegated, List Entity- If credentialing is not performed by the applicant, enter the name of the entity that does the credentialing. The name entered should match one of the entities listed on the "Entity Listing in Preparation for Monitoring Review" document that was previously provided to the RO.
Medical Group Affiliation - For each provider reflected on the table indicate the medical group/IPA affiliation for that provider. This data is necessary so that CMS may sort the table to assess provider network adequacy without requiring that a separate HSD 2 table be completed for each medical group/IPA that comprises a distinct health service delivery network. Note: Leave this column blank if the provider is not affiliated with a medical group/IPA. For example if you have a provider with a direct contract that is affiliated with a “XYZ” medical group/IPA you must input “DC” in column number 3 and the name of “XYZ” medical group/IPA in column 16. If your you provider has a direct contract but is not affiliated with a medical group/IPA then you must input “DC” in column 3 and leave column 16 blank.
Employment Status - Indicate whether the provider is an employee of a medical group/IPA 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.
2.7.3 Table HSD-2a: PCP/Specialist Contract Signature Page Index
The purpose of this index is to map contracted PCPs and specialty physicians listed in HSD2 to the tab indicating the template contract used to make official the relationship between the applicant and the provider. For SAE MA applicants, the grid will also document whether any of the applicant’s current providers will be part of the network available in the expansion area. If so, the provider should be reflected in the index to 1) establish the provider as a part of the contracted network for the expansion area, and 2) to provide the template contract used to formalize the arrangements. However, since these providers are already established as providers for the applicants, signature pages will not be requested to further support the existence of written arrangements. It is assumed that these arrangements were in place prior to the filing of the service area expansion.
Column Explanations:
PCP/Specialist - Enter the contract name as indicated in HSD2 for all PCPs and specialist contracts.
Contract Template/Tabs - Documentation to support the types of contracts executed should be submitted as part of this application. Enter the tab title/section to where the documentation supporting the arrangements between the physician and the applicant can be found. Then indicate the specific contract used for each physician reflected in the PCP/Specialist column.
Existing Network – Indicate whether the provider was previously established as a network provider in the applicants existing service area. (Not applicable for new MA applicants)
2.7.4 Table HSD-3: Arrangements for Medicare Required Services by County
Instructions:
Applicant must arrange contracted entities alphabetically by county and then alphabetically by type of provider. All direct and downstream providers of services should be listed.
Only list the providers who provide the Medicare required services that are listed in columns 9-28. Please do not list any additional providers or services.
If any providers listed on HSD-2 provide the services reviewed on HSD-3, list them as follows:
If all of the providers listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2" in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by all of the providers listed on HSD-2.
If all providers of a certain specialty listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2 with specialty (enter specialty) " in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by the providers of a certain specialty as listed on HSD-2.
If all providers who may serve as a "PCP" as listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2 who may serve as a PCP " in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by the providers that may serve as PCPs as listed on HSD-2.
Column Explanations:
Name of Provider - Enter name of contracted provider.
Type of Provider - Enter type of contracted provider.
ASC = Ambulatory Surgical Center
OPT = Outpatient physical therapy, occupational therapy, or speech pathology facility
CMHC = Community Mental Health Center
PH = Psychiatric Hospital
CORF = Comprehensive Outpatient Rehabilitation Facility
RAD = Radiology Therapeutic & Diagnostic
ESRD = Outpatient Dialysis Center
RH = Rehabilitation Hospital
FQHC = Federally Qualified Health Center
RHC = Rural Health Clinic
HHA = Home Health Agency
RNHC - Religious Nonmedical Health Care Institutions
HOSP = Acute Care Hospital
SNF = Skilled Nursing Facility
Lab = Laboratory
OTHER = any provider not listed above, such as durable medical equipment suppliers, transplant facilities, etc.
LH = Long Term Hospital
Steps 3-6
Location - Enter street address/city/state/zip code.
County Served by Provider - List one county the provider serves from this location. (If more than one county is served, repeat information as entered in columns 1-6 and columns 9-28, changing column 7 as applicable.)
Provider Previously Listed? - Enter "Y" if the same provider is previously listed in the rows above. Enter "N" if a provider is not previously listed in the rows above (e.g., the first time a provider listed on the worksheet.)
Steps 9-28
Services - Mark an "X" in the box if the provider/facility provides this service
2.7.5 Table HSD-3a: Ancillary/Hospital Contract Signature Page Index
The purpose of this index is to map contracted ancillary or hospital providers listed in HSD3 to the tab indicating the template contract used to make official the relationship between the applicant and the provider. The grid will also document whether any of the applicant’s current providers will be part of the network available in the expansion area. If so, the provider should be reflected in the index to 1) establish the provider as a part of the contracted network for the expansion county, and 2) to provide the template contract used to formalize the arrangements. However, since these providers are already established as providers for the applicant, signature pages will not be requested to further support the existence of written arrangements. It is assumed that these arrangements were in place prior to the filing of the service area expansion.
Column Explanations:
Ancillary/Hospital HSD3 – Enter the contract name as indicated in HSD3 for all ancillary and hospital contracts.
Tab Name – Indicate the Tab Name containing the template contract executed between the provider and the applicant.
Existing Network – Indicate whether the provider was previously established as a network provider in the applicant’s existing service area. (Not applicable for new MA applicants)
2.7.6 Table HSD-4: Arrangements for Additional and Supplemental Benefits
Instructions:
If there are other services that are not listed, add columns to the right of the "Screening-Vision" column to cover these services.
Only list the providers who provide the additional and supplemental benefit services as listed in the "services" columns (columns 7-12). Note: if other services are added to the right of the "Screening-Vision" column (column 12), those providers should also be listed.
If any providers listed on HSD-2 provide the services reviewed on HSD-4, list them as follows:
If all of the providers listed on HSD-2 provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2" in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by all of the providers listed on HSD-2.
If all providers of a certain specialty listed on HSD-2 provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2 with specialty (enter specialty) " in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by the providers of a certain specialty as listed on HSD-2.
If all providers listed on HSD-2 will serve as "PCPs" and provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2 who may serve as a PCP " in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by the providers that may serve as PCPs as listed on HSD-2.
All direct and downstream providers of services should be listed.
Arrange benefits alphabetically by county and then numerically by zip code.
Column Explanations:
Name of Provider - Enter name of the contracted provider, for example – Comfort Dental Group(Dental); Comfort Eyewear Associates (Eyeglasses/Contacts); Comfort Hearing Aids Associates (Hearing Aids); XYZ Pharmacy (Prescription Drugs – outpatient); Comfort Hearing, Inc. (Screening-Hearing); Comfort Vision Specialists (Screening – Vision).
Steps 2-5
Location - Enter street address/city/state/zip code, for example – 123 Main Street, Baltimore, MD 11111
County Served by Provider - List one county the provider serves from this location. (If more than one county is served, repeat information as entered in columns 1-5 and columns 7-12, changing column 6 as applicable.) Examples: Canyon County, Peaks County.
Steps 7-12-
Services - Mark an "X" in the box if the provider provides this service. For the providers that are listed in Column 1, please indicate which services are provided by this provider.
2.7.7 Table HSD-5: Signature Authority Grid
The purpose of this grid is to evidence whether physicians of a provider group are employees of the medical practice. The grid will display the medical group, the person authorized to sign contracts on behalf of the group and the roster of employed physicians of that group.
Column Explanations:
Practice Name – The name of the provider group for which a single signature authority exists on behalf of the group.
Signature Authority – The representative of the medical practice with authority to execute arrangements on behalf of the group
Physicians – Reflect all of the physicians in HSD2 for which the signature authority is applicable
2.8. Table: Essential Hospital Designation Table
Please complete this form with the indicated information about each hospital that applicant seeks to have designated as essential. Please note that, under Section 1858(h) of the Social Security Act (the Act) and 42 CFR 422.112(c)(3), applicant organization must have made a good faith effort to contract with each hospital that it seeks to have designated as essential. A “good faith” effort is defined as having offered the hospital a contract providing for payment rates in amounts no less than the amount the hospital would have received had payment been made under section 1886(d) of the Act. The attestation on the following page must be completed and submitted with the completed chart.
PART 6 LISTS OF REQUESTED DOCUMENTS
The following is a summary of the documentation that must be submitted with the Medicare Advantage application. To assist in the application review Applicant’s must submit these documents using the file name provided in the table. Applicants are encouraged to use the file name format that is provided below. If the Applicant is required to provide multiple versions of the same document, the Applicant should insert a number, letter, or even the state behind the file name for easy identification.
Part 2 Initial Applications--Section 1-- All MA Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
1.1 Experience & Organization History
|
No |
PDF. File |
HXXX_History-1. pdf |
|
1.2 Administrative Management |
Yes |
PDF. File |
HXXX_Insurance-1.pdf |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_StateLicense-StateAbbreviation.pdf |
|
1.3 State Licensure
|
Yes |
PDF. File |
Hxxxx_StateCert-StateAbbreviation.pdf |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_StateDBA-StateAbbreviation.pdf |
|
1.4 Business Integrity
|
No |
PDF. File |
Hxxxx_IntegrityDis.pdf |
|
1.6 Key Management Staff
|
No |
PDF. File |
Hxxxx_KeyManagement.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_AuditedStatements.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_ANAICFinancialPlan.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_QuarterlyHealthBlanK.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_FinancialPlan.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_FinancialDisclosure.pdf |
|
1.8 Service Area
|
No |
PDF. File |
Hxxxx_PartialCountyJust.pdf |
|
1.8 Service Area
|
No |
PDF. File |
Hxxxx_County
Name-GeoScrptMaps.pdf |
|
1.9 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderTable.pdf |
|
1.9 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_PContract-Template
1-PCP.pdf, Hxxxx_PContract-Template 2-IPA.pdf |
|
1.9 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_
DownstreamContract-Template
1-MG.pdf.
Hxxxx_DownstreamContract-Template 1-IPA.pdf |
|
1.9 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderMatrix
–Template 1-MG.pdf. |
|
1.10 Contracts for Administrative & Management Services |
No |
PDF. File |
Hxxxx_AdminContract (number, version, or template).pdf
|
|
1.10 Contracts for Administrative & Management Services |
Yes |
PDF. File |
Hxxxx_AdminDelContractMatrix (number, version, or template).PDF |
|
1.11 Health Services Delivery (HSD)
|
Yes |
Excel File |
Hxxxx_HSD1.County Name.xls
Hxxxx_HSD2.County Name.xls |
|
1.18 |
Yes |
PDF. File |
Hxxxx_DUA.pdf |
Part 2 Initial Applications--Section 2 –RPPO Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateLicense-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_StateCert-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateDBA-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccesStandards (Urban or Rural).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccessStandardsChart (State Abbreviation).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_ContingenyPlanAccess.pdf |
|
2.3 Essential Hospital
|
Yes |
Excel File |
Rxxxx_EssentialTable.xls |
|
2.3 Essential Hospital
|
Yes |
PDF. File |
Rxxxx_EssenstialAttest(Hospital Name).pdf |
Part 2 Initial Applications--Section 3-PPO Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
3.1 Access to Services |
Yes |
Excel File. |
Hxxxx_HSD1.County Name.xls
Hxxxx_HSD2.County Name.xls |
|
3.1 Access to Services |
No |
PDF. File |
Hxxxx_NationalCoverageScipt.pdf |
|
3.1 Access to Services |
No |
PDF. File |
Hxxxx_DiversityScrpt.pdf |
|
3.3 Payment Provisions
|
Model Guidance |
PDF. File |
Hxxxx_ReimbursementGrid.pdf |
Part 2 Initial Applications--Section 4- MSA/ MSA Demo
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
4.2 Access to Services
|
Yes |
Excel File |
Hxxxx_HSD1.County Name.xls
Hxxxx_HSD2.County Name.xls |
|
4.4 Payment Provisions
|
Model Guidance |
PDF. File |
Hxxxx_ReimbursementGrid.pdf |
Part 2 Initial Applications--Section 5- MSA DEMO ONLY
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_CostsharingScript.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_PreventServices.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_ProjectedEnrolllment.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_NonMedicareSrvcs.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_DepositsScript.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_EnrollmentTracking.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_RecoverDeposits.pdf |
Part 3 Service Area Expansions--Section 1--All MA Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_StateLicense-StateAbbreviation.pdf |
|
1.2 State Licensure
|
Yes |
PDF. File |
Hxxxx_StateCert-StateAbbreviation.pdf |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_StateDBA-StateAbbreviation.pdf |
|
1.3 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderTable.pdf |
|
1.3 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_PContract-Template
1-PCP.pdf, Hxxxx_PContract-Template 2-IPA.pdf |
|
1.3 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_
DownstreamContract-Template
1-MG.pdf.
Hxxxx_DownstreamContract-Template 1-IPA.pdf |
|
1.3 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderMatrix –Template 1-MG.pdf. |
|
1.4 Contracts for Administrative & Management Services |
No |
PDF. File |
Hxxxx_AdminContract (number, version, or template).pdf
|
|
1.4 Contracts for Administrative & Management Services |
Yes |
PDF. File |
Hxxxx_AdminDelContractMatrix (number, version, or template).PDF |
|
1.5 Health Services Delivery (HSD)
|
Yes |
Excel File |
Hxxxx_HSD1.County Name.xls
Hxxxx_HSD2.County Name.xls |
|
1.6 Service Area
|
No |
PDF. File |
Hxxxx_PartialCountyJust.pdf |
|
1.6 Service Area
|
No |
PDF. File |
Hxxxx_County
Name-GeoScrptMaps.pdf |
Part 3 Service Area Expansion--Section 2 --RPPO Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateLicenseNJ.pdf
|
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_StateCertNY.pdf |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateDBA-NJ.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccesStandards (Urban or Rural).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccessStandardsChart (State Abbreviation).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_ContingenyPlanAccess.pdf |
|
2.3 Essential Hospital
|
Yes |
Excel File |
Rxxxx_EssentialTable.xls |
|
2.3 Essential Hospital
|
Yes |
PDF. File |
Rxxxx_EssenstialAttest(Hospital Name).pdf |
Part 4 Solicitation of Special Needs Proposals
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
See subsets within Solicitation |
See Attachment Section |
Following Instructions |
See Solicitation Instructions |
List available at http://www.cms.hhs.gov/HealthPlansGenInfo/Downloads/cmsregional.pdf
RO I CMS – BOSTON REGIONAL OFFICE
JOHN F. KENNEDY FEDERAL BUILDING, ROOM 2375, BOSTON, MA 02203
TELEPHONE: 617-565-1267
STATES: CONNECTICUT, MAINE, MASSACHUSETTS, NEW HAMPSHIRE, RHODE ISLAND, AND VERMONT
RO II CMS – NEW YORK REGIONAL OFFICE
26 FEDERAL PLAZA, ROOM 3811, NEW YORK, NY 10278
TELEPHONE: 212-616-2358
STATES: NEW JERSEY, NEW YORK, PUERTO RICO, and VIRGIN ISLANDS
RO III CMS – PHILADELPHIA REGIONAL OFFICE
PUBLIC LEDGER BUILDING, SUITE 216, 150 S. INDEPENDENCE MALL WEST, PHILADELPHIA PA 19106-3499
TELEPHONE: 215-861-4224
STATES: DELAWARE, DISTRICT OF COLUMBIA, MARYLAND, PENNSYLVANIA, VIRGINIA, WEST VIRGINIA
RO IV CMS – ATLANTA REGIONAL OFFICE
ATLANTA FEDERAL CENTER, 61 FORSYTH ST., SW, SUITE 4T20, ATLANTA, GA 30303-8909
TELEPHONE: 404-562-7362
STATES: ALABAMA, FLORIDA, GEORGIA, KENTUCKY, MISSISSIPPI, NORTH CAROLINA, SOUTH CAROLINA, AND TENNESSEE
RO V CMS – CHICAGO REGIONAL OFFICE
233 NORTH MICHIGAN AVENUE, SUITE 600, CHICAGO, IL 60601-5519
TELEPHONE: 312-353-3620
STATES: ILLINOIS, INDIANA, MICHIGAN, MINNESOTA, OHIO, AND WISCONSIN
RO VI CMS – DALLAS REGIONAL OFFICE
1301 YOUNG STREET, Room 833, DALLAS, TX 75202
TELEPHONE: 214-767-4471
STATES: ARKANSAS, LOUISIANA, OKLAHOMA, NEW MEXICO, AND TEXAS
RO VII CMS – KANSAS CITY REGIONAL OFFICE
RICHARD BOLLING FEDERAL OFFICE BUILDING, 601 EAST 12th ST., ROOM 235, KANSAS CITY, MO, 64106
TELEPHONE: 816-426-5783
STATES: IOWA, KANSAS, MISSOURI, AND NEBRASKA
RO VIII CMS -- DENVER REGIONAL OFFICE
1600 BROADWAY, SUITE 700, DENVER, CO 80202
TELEPHONE: 303-844-2111
STATES: COLORADO, MONTANA, NORTH DAKOTA, SOUTH DAKOTA, UTAH, AND WYOMING
RO IX CMS – SAN FRANCISCO REGIONAL OFFICE
DIVISION OF MEDICARE HEALTH PLANS
90 7th Street Suite 5-300 (5W), SAN FRANCISCO, CA 94103-6707
75 HAWTHORNE STREET, 4th Floor, SAN FRANCISCO, CA 94105-3901
TELEPHONE: 415-744-3617
STATES: ARIZONA, CALIFORNIA, GUAM, HAWAII, NEVADA, AND AMERICAN SAMOA, AND THE COMMONWEALTH OF NORTHERN MARIANA ISLAND
RO X CMS -- SEATTLE REGIONAL OFFICE
MEDICARE MANAGED CARE BRANCH
2201 6th AVENUE, RX-47, ROOM 739, SEATTLE, WA 98121-2500
TELEPHONE: 206-615-2351
STATES: ALASKA, IDAHO, OREGON, AND WASHINGTON
1 How to Select a Frail Elderly Population? A Comparison of Three Working Definitions; Paw, Dekker, Fesken, Schouten and Kromhout, Journal of Clinical Epidemiology, Volume 52, Issue 11, November 1999, pages 1015-1021
Draft Final 2009 Master
Application, 1-10-2-20078 (redline) Page
| File Type | application/msword |
| File Title | PART I- FOR APPLICANTS THAT ARE SUBMITTING INITIAL APPLICANTIONS |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2008-01-10 |
| File Created | 2008-01-10 |