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pdfComment
Number
Source of Comment:
(Company Name)
2013 MA
Application
Version #__ (60
day or 30 day)
Application Part
Application Section (Number/ Header)
Application
Description of the Issue or Question
Page Number
Comments & Recommendation(s) from Source
Type of Suggestion
(Insertion Deletion, or
Revision)
1
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Some recruitment efforts struggle with meeting both of CMS' time and distance requirements. Will CMS reconsider health plans as meeting criteria if at least one
(time OR distance) is met? Example geographical terrain in rural
areas impedes meeting criteria requirements.
2
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Because of contracting issues (providers not willing to accept MA rates), we typically do not
recruit free standing radiology centers to provide Diagnostic Radiology or Mammography.
Instead these services are directed to Acute Inpatient Hospitals or received at PCP or
Specialist.
Will CMS reconsider Diagnostic Radiology/Mammography as a
required Facility specialty type?
Revision
3
United Healthcare
60day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Medicare.gov is our main source of truth in terms of comparison of our networks.
Will there ever be an opportunity to review providers based on
specialty type in excess of a 25 mile range? Will CMS update their
web site to offer searching criteria beyond 25 mile range?
Revision
4
United Healthcare
60 dau
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Medicare.gov lists services available at an Acute Inpatient Hospital, yet the hospital
operating certificate is not approved by DOH to provide those services, or the hospital
confirms they do not provide those services.
How do we address a service or provider that is posted to
Medicare.gov as being Medicare participating and those
providers are used to judge our network adequacy/accessibility,
but we find out through provider verification that they do not
perform the services or are not participating? (ie outpatient
cardiac catherization v. cardiac surgery)
Revision
5
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
CMS requires information that is not readily or easily available for use in an automated
fashion. For instance, the number of Medicare certified beds for hospitals, SNFs, ICUs and IP
Psych facilities is not readily available to MCOs. This is also true of Medicare certification
numbers.
We believe that CMS's requirements for this data is
administratively burdensome. Therefore, we request that CMS
provide certain information downloadable in excel or other data
files that will assist plans in their automated production of HSD
tables and population of these fields with accurate CMS
information. For example, CMS should provide a resource from
which MCOs can obtain Medicare Certification #s, bed counts, etc
so that this information is consistent across all health plans.
Insertion
6
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Release of HSD Tables Prior to Final Release of Application in Early January.
Release of HSD Tables Prior to Final Release of Application in Early
January: While it is recognized and appreciated that CMS
provides draft applications earlier iin the year, we request that
the final HSD Tables be made available by November or
December rather than with the release of the Final Application in
early January. This would allow organizations with a high volume
of submissions additional time to train network personnel and
sufficient time to upgrade HSD tools, excel formulas, etc. on any
changes made to the tables.
Revision
7
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Not all document revisions are dated in the naming convention to know that those
downloaded from HPMS are the same as those posted on CMS website.
All documents posted to this site should be dated in the naming
convention: http://www.cms.gov/MedicareAdvantageApps/
Revision
8
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
For Large Metro and Metro counties that in addition to one or more urban centers also
contain large rural areas where physicians are not available (forests, reservations, military
bases, etc) and the number of Medicare beneficiaires is low or non-existent in these areas.
We recommend CMS consider adjusting the criteria either by
using a lower level county classification or by lengthening the
distance standards for certain specialists in those geographically
challenged counties to better compensate for these geographical
differences within a county? How do we approach this with
CMS?
Revision
9
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Medicare.gov does not provide downloadable files of providers performing these services:
Cardiac Surgery, Cardiac Catheterization, Outpatient Infusion Chemo, Mammography, and
Outpatient Dialysis.
How does CMS determine availability of services? What are CMS'
definitions of these services?
N/A
Revision
10
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
CMS Exception form required for 2014 - DISTANCE FROM BENEFICIARIES IN THE COUNTY
field.
We recommend that CMS provide clarity & direction on how they
want health plans to use the Sample Beneficiary file, HSD
Beneficiary Coverage by Zip Code Report, and the Part D Eligibility
File, and more detailed instructions on how CMS is calculating
distances.
Revision
11
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Certification number: The lists of certified providers that we receive from CMS'
(downloadable files from their website) does not always show all locations of a contracted
provider. Ex: Walgreens - CMS's lists show some Walgreens' locations, but not all of the
locations that we have contracted.
We need clarification from CMS if not all locations are certified or
if we are to assume our national and multi-location contracts are
covered under the main provider's certification number.
Revision
12
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
It is redundant/duplicative to require health plans to repeat listing the contracted
providers/facilities "that will ensure access" on the Exception form when they are already
listed on the HSD table.
It is suggested that the exception form only require the health
plan to identify the "closest contracted provider".
13
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
With the suggested change in requiring complete copies of executed Medicare contracts and We would like CMS to consider lengthening the time frame in
any applicable downstream agreements, the standard previous turnaround time may be too which health plans have to provide complete executed Medicare
short.
agreements (including any applicable downstream agreements).
The suggested timeframe would be 15 days.
Revision
14
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
CY 2014 HSD Application Instructions reference column Q (Model Contract Amendment Indicate if contract uses CMS Model MA Contract Amendment by entering Yes or No) in the
MA Provider Table section.
Will CMS be adding a column Q to the Provider Table? Column Q
appears in CY 2014 Instructions but not in Provider Table sample
or the CMS summary of changes. Our HSD table needs to be built
to include this or be subject to HPMS upload fail. We would also
need a copy of the Model Contract Amendment to know what
CMS is referencing. Where is it available?
Revision
15
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
The CMS downloadable certified Transplant facilities list is in PDF format requiring
considerable manual manipulation to convert to Excel or Access so that it can be used in an
automated reporting
Request that CMS produce certified transplant list in a .txt or
Excel/Access, similar to the other website posted downloadable
files of CMS certified providers (Hospital, Home Health, DME, etc)
Revision
16
United Healthcare
60 day
Instructions
2.9 Health Services Delivery (HSD) Tables Instructions
19
Certain Orthotic & Prosthetic providers can serve a county without necessarily being located Could CMS reconsider Orthotics & Prosthetics differently, for
in the county, e.g. a mail order vendor supplying directly to the home. In addition, we’ve
example, similar to home health?
noticed that CMS is including retail vendors such as Walmart, CVS, etc. in the O&P category
when MA plans may focus on more typical orthotic suppliers who can customize the
orthotics/prosthetics, etc. or provide them through hospitals or physician offices.
Revision
17
United Healthcare
60 day
Attestations
3.7 Fiscal Soundness
28
3.7(A)(2) is duplicative of 3.3(A)(1); that is we attest to state licensing twice.
United suggests that Section 3.7(A)(2) be deleted as it appears it
is duplicative of 3.3(A)(1).
Deletion
18
United Healthcare
60 day
Attestations
3.9 CMS Provider Participation Contracts & Agreements 30
(Section B)
As part of the application review process, Applicants will need to provide fully executed
contracts for physicians/providers that CMS reviewers select based upon the CMS Provider
and Facility tables that are part of the initial application submission. CMS reviewers will list
the providers/facilities and specific instructions in CMS’ first deficiency notice. 4.3 CMS
Provider Contract Matrix
Instructions for CMS Provider Contract Matrix
This matrix must be completed by MA Applicants and should be used to indicate the location
of the Medicare requirements in each contract / agreement for the Applicant’s first tier,
downstream and related entity providers that CMS has identified in the contract sample.
The new requirement requires more uploading since entire
contracts are requested rather than just signature pages. It also
requires provider matrices produced for each selected sample
during the shorter deficiency period rather than with the initial
application filing. Can CMS provide the sample size per
application they expect to request, expected length of the
window for uploading requested contracts and matrices, and the
zip file size maximum that HPMS will accept?
Revision
N/A
19
Ucare
60 day
Attestations
3.10 Contracts for Administrative & Management
Services
30
Regarding attestation #15 under section 3.10.A, is this the time period for the previous two
calendar years when a plan may have received an automatic
renewal? Or is this the previous two times that a plan has completed an application, either
as a service area expansion or a new application regardless of the time between such
applications?
Please verify what is meant by “at least one of the past two
Medicare Advantage application review cycles.”
20
United Healthcare
60 day
Attestations
3.13 Marketing (Section A.4.)
37
Applicant agrees to provide general coverage information, as well as information concerning We request clarification of specifically which materials are to be
utilization, grievances, appeals, exceptions, quality assurance, and financial information to
made available "upon request" as this language is not reflected in
any beneficiary upon request.
42 CFR 422.2260 through 42 CFR 422.2276, referenced in the first
paragraph of Section 3.13 of the Part C - Medicare Advantage and
1876 Cost Plan Expansion Application.
21
United Healthcare
60 day
Attestations
3.16 Claims (Section A.4.)
42-43
We think that the addition of the word “complete” in this attestation will more closely align
with the CMS requirements and with United’s claims processing policies. For example,
United does not “develop” all claims that are incomplete, such as certain claims that are
missing information or have invalid coding. These claims typically involve only provider
liability, so they would not affect the member. This slight change in the attestation wording
would allow United to answer this attestation with a “yes” without having to qualify our
response.
We believe that the addition of the word “complete” in this
attestation will more closely align with CMS requirements to
process complete claims promptly. We recommend that the
attestation be revised by inserting the word “complete,” as
follows:
N/A
N/A
Revision
"Applicant will comply with all applicable standards, requirements
and establish meaningful procedures for the development and
processing of all complete claims including having an effective
system for receiving, controlling, and processing claims actions
promptly and correctly."
22
United Healthcare
60 day
Attestations
3.16 Claims (Section A.3.)
42
Applicant agrees to give beneficiary prompt notice of acceptance or denial of a claim's
payment in a format consistent with the appeals and notice requirements stated in 42 CFR
Part 422 Subpart M.
CMS rules do not require that plans provide notice of claim
acceptance when there is no cost share involved (except for PFFS
claims). There is also no requirement to notify beneficiaries of
claim denials when the claim only involves provider
reimbursement (such notices would be confusing to
beneficiaries). Rather, the requirement is that when a claim is
denied resulting in member liability, plans must provide the
member with his or her appeals rights. We suggest an addition to
the attestation that explains that the notice is required in all
cases where there is cost-sharing or member liability. We request
that the attestation be revised as follows: Applicant agrees to
give beneficiary prompt notice of acceptance or denial of a claim's
payment in a format consistent with the appeals and notice
requirements stated in 42 CFR Part 422 Subpart M, in all cases
where there is a member cost-sharing or member liability.
Insertion
23
United Healthcare
60 day
Attestations
3.28 Tiering of Medical Benefits (Section A.1.)
58
All beneficiaries have equal access to the various tiers proposed. Note: this is new for 2014
We request clarification of "various tiers" as this term is not
reflected in 42 CFR 422.112.
Revision
24
UCare
60 day
Attestations
3.28 Tiering of Medical Benefits (Section A.1.)
58
If a plan does not tier benefits, would they answer the attestation (“equal
access to the various tiers proposed”) as yes or no if no tiers are proposed? A not
applicable option would be more accurate.
For section 3.28, tiering of medical benefits, we suggest adding a
column for not
applicable.
Revision
25
United Healthcare
60 day
Document Upload Templates
4.3 CMS Provider Contract Matrix (Number 3)
67
Designate if the contract uses the CMS Model Medicare Advantage contract amendment
with a "(M)" next to the provider/facility name.
We believe the "CMS Model Medicare Advantage contract
amendment" document has not been released and we would like
to know when it will be released.
26
Ucare
60 day
Document Upload Templates
4.13 Tiering of Medical Benefits Request Document
86
Not provided
For section 4.13, we suggest including instructions that this is
optional if tiering of
benefits is not offered.
Revision
27
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
Specific Requirements for Dual-Eligible SNPs (State
Medicaid Agency Contracts)
89
We encourage CMS to provide flexibility with the deadlines for completing State Medicaid
Agency contracts. There may be cases where state legislative activity or the start of
Financial Alignment Demonstration plans may make it difficult to complete the contract by
July 1st.
We recommend removal of the reference to a July 1 deadline for
submitting State Medicaid Agency contracts.
Deletion
28
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
Definitions
92-93
Can clarification be provided on when the "Dual Eligible Subset - Zero Dollar Cost Share"
designation or the "Dual Eligible Subset" designation should be used?
We request an example of when these designations should be
used.
29
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
4. D-SNP Proposal Application
97
Not provided
Please clarify what material needs to be submitted for an existing
D-SNP that is changing its subtype. Is the entire SNP proposal
needed when changing D-SNP subtypes?
30
Ucare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
6. D-SNP State Medicaid Agency(ies) Contract(s)
(Attestations #2 and #8)
98
None provided
Questions #2 and #8 are duplicative.
Deletion
31
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
11. Model of Care Attestations (Provider Network and
Use of Clinical Practice Guidelines)
104
Under the "Provider Network and Use of Clinical Practice Guidelines" category, item #59
states, "Applicant conducts periodic surveillance of employed and contracted providers to
assure that nationally recognized clinical protocols and guidelines are used when available
and maintains monitoring data for review during CMS monitoring visits), the term
"contracted providers". This statement implies that the Applicant will need to conduct
surveillance of all providers, Therefore, this raises concerns about this applicability to the
broader provider network that can be several thousand providers.
We recommend that this section be modified so that a sampling
can be used in monitoring surveillance.
Revision
32
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
14. D-SNP Upload Document (Number 3)
115
Under the 2011 D-SNP State Medicaid Agency Contract Upload Document, item #3, bullet #3 We recommend that reference to "third party liability" be
states, "Third party liability and coordination of benefits". We believe that clarify is needed removed because CMS has not provided clear direction as to
with regard to the meaning of "third party liability."
what is meant be this. As an alternative, CMS needs to clarify or
provide background on "third party liability" in this context.
Deletion
33
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
14. D-SNP Upload Document (Number 5)
115
a. There is a significant amount of confusion for both D-SNPs and State Medicaid Agencies
as to whether the State Medicaid Agency contract requires the D-SNP to provide Medicaid
services. Please clarify that the provision of Medicaid benefits is not always required and
that increased levels of agreed-upon coordination of Medicaid benefits is also acceptable.
Revision
b. Specifically, the NOTE comment only makes reference to Medicaid services "that the
organization is obligated to provide under its State contract," which is confusing without a
reference to coordination of services as another alternative.
We are assuming that this section would only be included if the
State Medicaid Agency contract requires the D-SNP to provide
Medicaid services. Broadly, if State Medicaid Agencies and MAOs
determine that increased coordination will best serve duallyeligible members, the requirements should be clarified to allow
this. Specifically, in item #5 and elsewhere that references
providing Medicaid benefits, clarify in these areas that agreedupon coordination is acceptable.
N/A
N/A
34
United Healthcare
60 day
APPENDIX I: Solicitations for Special Needs Plan
(SNP) Proposals
15. D-SNP State Medic aid Agency Contract Matrix
(Element #3)
117
The third element of the Dual SNP contract matrix provides that:
Medicaid benefits covered under the SNP
These are the Medicaid medical services that the organization is obligated to provide under
its State contract, not the non-Medicare mandatory Part C services covered under the MA
contract.
There is confusion about what should be documented for this element. Further the above
description makes it sound like the D-SNP is required to provide Medicaid benefits, when in
fact most D-SNPs do not provide/cover Medicaid benefits, but rather help members to
coordinate the services available through Medicare and Medicaid.
35
UnitedHealthcare
60 day
APPENDIX II: Employer/Union-Only Group Waiver
Plans (EGWPs) MAO "800 Series"
6.4 Attestations ; 2 Certification (Number 9)
135
Flexibility should be provided to allow the Medicaid benefits to be
documented in a variety of ways that will accommodate each
state's unique negotiated approach. For example, due to the
overlap of benefits covered by both Medicare (primary) and
Medicaid (secondary), if a state wants a combined list of Medicaid
and Medicare benefits outlining each program's responsibility for
a category of service, that should be sufficient to meet this
element and will help MAO's create a better Section IV of the
Summary of Benefits.
Applicant understands that dissemination/disclosure materials for its EGWPs are not subject We believes that the correct citations are 42 CFR 422.2262 and 42
to the requirements contained in 42 CFR 422.80 or 42 CFR 423.50 to be submitted for review CFR 423.2262, respectively.
and approval by CMS prior to use.
N/A
Revision
CMS Decision (Accept, Accept with Modification, Reject, Clarify)
Reject: Recruitment is a plan issue as to timing, effort, flexibility on payment
arrangements, use of commercially-contracted network, leverage, etc. If terrain in a rural
area is a barrier to transportation and access for health care and other services, the
particular circumstances should be explained during the application process for the
county in question via the exception process after the initial deficiency letter is received.
Clarify: This needs to be clarified. A PCP or Specialist who operates his or her own
state and federally approved radiology and/or mammography equipment in the office
could be used as could a hospital's OP radiology department.
Accept: CMS is looking into expanding the search radius early next year. It has not
been implemented due to technical database issues.
Clarify: Medicare.gov information should not be the sole source of information about
the Medicare status of individual services or components operated by a hospital. Due
dilligence with regard to this issues is the responsibility of the plan bulding a Medicare
Advantage network and the specifics of what the facility says about these services needs
to be confirmed by documents and written assurances, not taken over the phone from
one individual.
Reject: This type of information is well known in multiple departments aand offices of
these facilities and often maintained on their website or in other public relations and
business documents for external users to request. No government data base is going to
be as current and up to date as the facility's own official record in the CEO or CFO's
office.
Accept with Modification: We will look into the possibility of an earlier release of the
final format of the HSD Tables prior to the release of the final version of the application
in January.
Accept with Modification: We will look into this with HPMS and our contractors for
possible improvement.
Reject: This example is one of the reasons why we offer the applicant the exception
process. We are aware of differences across single counties, especially large counties,
and have looked very carefully at how competing applicants and existing applicants have
been able to structure their delivery networks in these counties or in more rural or other
unique characteristics of parts of these counties.
Reject: Definitions of these services are available from Medicare. We determine
availiabilty of these services from private and public data and FFS claims file information
as well as the provider networks of other managed care organizations operating in the
same area.
Accept with Modification: We will share this with the staff working to improve guidance
and instructions and the automated fields for active consideration.
Accept with Modfication: We will research this topic in CMS and clarify in instructions
whether or not an application can assume national and multi-location contracted provider
sites are covered under a "main provider" certification number.
Reject: The exception template information is reviewed on its own merits with reference
to HSD Tables by an exception team reviewer and others on the national team. These
staff need to understand and the plan needs to affirmatively state the choices that will be
available to Medicare enrollees to get the service in the most timely manner, not just one
choice.
Clarify: We will refer this suggestion to the workgroup revising the entire contract
review approach.
Accept: CMS will add column Q to the Provider Table and plans to release the CMS
Medicare Advantage Contract Amendments for both provider and administrative
contracts in the early fall of 2012.
Accept with Modification: We are willing to look into making this list available in
another format for a manipulable file capacity.
Accept: We are making changes of this nature for 2014 application.
Accept: The second reference to state licensure in attestation 3.7 (A)(2) will be
removed from the Fiscal Soundness section.
Accept with Modification: Because CMS is no longer asking for provider contract
templates, the agency anticipates a reduced burden for applicants in the initial application
submission. CMS will identify the provider contract sample based upon the contracted
network. As it has in the past with the signature page sample, the number of contracts
included in that sample will depend upon the size of the requested service area and
number of contracted providers serving the pending area. Thus, we cannot provide a set
contract size that will apply to every applicant. CMS does not anticipate lengthening the
period of time during which applicants will respond to the initial deficiency notice. The
previous time frames have been adequate for applicants to locate and upload signature
pages; CMS anticipates the same time frames will be adequate for the full contract
upload. The upload file size remains unchanged from last year at 500 MB.
Clarify: CMS is asking for applicants to attest YES or NO as to whether the applicant
has submitted an initial or SAE Medicare Advantage application during one (or both) of
the previous two application review cycles (i.e., February 2012 or February 2011
submissions) and been approved for one (or both) of those applications. If the applicant
attests YES, then the applicant does NOT need to upload executed administrative
contracts with the application filing in Feburary 2013 (for contract year 2014). CMS
does not consider an automatic renewal of a Medicare Advantage contract from one year
to the next without an application submission to meet this criteria.
Clarify: Per 42 CFR 422.111 (c), an MA organization must disclose specific information
upon request. This information includes, but is not limited to, the following: the
procedures the organization uses to control utilization of services and expenditures;
grievance information according to 422.564; and appeals information according to
422.578. CMS clarifies that the applicant could fulfill a request for the aforementioned
information by providing the Evidence of Coverage document. Additionally, 42 CFR
422.111 (c) (5) requires the MA organization to fulfill requests for the financial
condition of the MA organization, including the most recently audited information
regarding, at least, a description of the financial condition of the MA organization
offering the plan. MA organizations have flexibility in creating materials to fulfill a
request for information on their financial condition. At a minimum, the material would
need to include the elements noted in 42 CFR 422.111 (c) (5).
Disagree: The requirement in 42 CFR 422.520 is that “clean” claims be paid promptly
(within 30 days) and that all other claims be paid or denied within 60 days.
Accept with the following modifications: Applicant agrees to give beneficiary prompt
notice of acceptance or denial of a claim's payment in a format consistent with the
appeals and notice requirements stated in 42 CFR Part 422 Subpart M and in accordance
with CMS guidance, in all cases where there is a member cost-sharing or member
liability.
Clarify/Accept: Please note tiering will be deleted from the CY 2014 Part C MA
application. For further clarification, tiering is not a requirement by CMS. Tieiring is
optional for organizations that want to offering tiered networks in their medical benefits.
Various tiers refers to the amount of tiers an organization chooses to offer within their
plan. A plan may not offer more than three tiers withiin a service category. For ex. A
plan may offer a three tier hopsital network, where the cost sharing would vary
accoording to each tier.
Clarify/Accept: Please note tiering will be deleted from the CY 2014 Part C MA
application. For further clarification, tiering is not a requirement by CMS. Tieiring is
optional for organizations that want to offering tiered networks in their medical benefits.
Not all organizations offer tiering of their medical benefits, therefore, this column could
be added to clarify this information.
Clarify: CMS plans to release Medicare Advantage Contract Amendments for both
provider and administrative contracts in the fall of 2012.
Clarify/Accept: Please note tiering will be deleted from the CY 2014 Part C MA
application. For further clarification, tiering is not a requirement by CMS. Tieiring is
optional for organizations that want to offering tiered networks in their medical benefits.
CMS will ensure that it is explained more clearly in our instructions or other material that
this type of benefit offering is optional.
Reject: We believe the July 1 deadline for submitting State Medicaid Agency contracts is
flexible, and has been in place over the past 2 years.
Clarify: The Dual eligible subset type allows for enrollment of - any (or all) categories
of eligibility provided there is State agreement. It is the most flexible classification of DSNP. The DE Subset D-SNP type can be further designated as a zero dollar cost share
when the Subset enrolled includes the Medicaid categories with 0 dollar Medicare cost
share, that is, QMB and QMB + , and/or any other Medicaid category, e.g., FBDE, when
the State has agreed to cover the Medicare cost share for that Medicaid eligibility group
in its State plan.
Clarify: An existing D-SNP will need to submit a new SNP proposal in the next year if it
is changing its D-SNP type. Because this past year was the first year where a State
contract was required for all D-SNPs, and there was confusion on the part of States and
D-SNPs, we underwent a one time D-SNP type mismatch correction process.
Reject: Questions two and eight are different because question two is asking the
applicant if they want the contract with the State Medicaid Agency(ies) to be reviewed to
determine fully integrated dual eligible (FIDE) status. Question eight specifies the period
in which the contract should be reviewed, i.e., do they wish to have the contract
reviewed for FIDE for the same period(s) as indicated for MIPPA compliance as
answered to questions 6 and 7. This question seeks to determine that if the contract is a
multi-year contract or an evergreen contract, whether it is the MAOs intention that FIDE
determination be made for the same period(s).
Reject: We do not believe this modification is necessary because sampling is an
acceptable method of surveillance.
Accept with Modification: This comment is referencing an old form that is no longer in
use. A new Upload form will be inserted into the application document.
Accept with Modification: This comment is referencing an old form that is no longer in
use. A new Upload form will be inserted into the application document. The language in
the "Note" should read "provide or arrange". The old form says "provide and arrange".
CMS does not feel that additional changes other than this needs to be made as the
guidance in Chapter 16-B and all trainings cover this area in detail.
Reject: Submission of combined lists results in CMS not being able to determine the level
of actual coordination and integration.
Accept: However, we should note that while CMS does not currently require submission
of marketing materials for pre-approval it resereves the right to review EGWP related
marketing material at any time.
| File Type | application/pdf |
| Author | CMS |
| File Modified | 2012-09-13 |
| File Created | 2012-09-13 |