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pdfPART C -MEDICARE ADVANTAGE
and 1876 COST PLAN EXPANSION
APPLICATION
For all new Applicants and existing Medicare Advantage contractors seeking
to expand a service area -- CCP, PFFS, MSA, RPPO, SNPs, and EGWPs
For all existing Medicare Cost Plan contractors seeking to expand the
contract service area
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services (CMS)
Center for Medicare (CM)
Medicare Drug and Health Plan Contract Administration Group
(MCAG)
Medicare Advantage Coordinated Care Plan (CCPs) must offer at least one
Medicare Advantage plan that includes a Part D prescription drug benefit
(MA-PD) in each county of its service area. Therefore, CCP Applicants must
timely submit a Medicare Advantage-Prescription Drug (MA-PD) application
to offer Part D prescription drug benefits as a condition of approval 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. This collection will expire January 31, 2014. The time required to complete this information collection is estimated to
average 35 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.
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1
GENERAL INFORMATION ........................................................ 5
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
2
Overview ............................................................................................................. 5
Types of MA Products ........................................................................................ 5
Important References .......................................................................................... 6
Technical Support ............................................................................................... 6
The Health Plan Management System (HPMS) ................................................. 8
Submitting Notice of Intent to Apply (NOIA).................................................... 9
Additional Information ....................................................................................... 9
Due Date for Applications ................................................................................ 11
Request to Modify a Pending Application ........................................................ 12
Application Determination and Appeal Rights ................................................. 13
INSTRUCTIONS .......................................................................... 14
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
3
Overview ........................................................................................................... 14
Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans
(EGWPs) ........................................................................................................... 14
Applicants Seeking to Offer Employer/Union Direct Contract MAO.............. 15
Applicants Seeking to Offer Special Needs Plans (SNPs)................................ 15
Applicants Seeking to Offer Medicare Cost Plans ........................................... 15
Applicants Seeking to Serve Partial Counties .................................................. 16
Types of Applications ....................................................................................... 16
Chart of Required Attestations by Type of Applicant ...................................... 16
Health Services Delivery (HSD) Tables Instructions ....................................... 18
Document (Upload) Submission Instructions ................................................... 19
MA Part D (MA-PD) Prescription Drug Benefit Instructions .......................... 19
ATTESTATIONS.......................................................................... 20
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
Experience & Organization History.................................................................. 20
Administrative Management ............................................................................. 20
State Licensure .................................................................................................. 22
Program Integrity .............................................................................................. 25
Compliance Plan ............................................................................................... 25
Key Management Staff ..................................................................................... 26
Fiscal Soundness ............................................................................................... 27
Service Area ...................................................................................................... 27
CMS Provider Participation Contracts & Agreements ..................................... 28
Contracts for Administrative & Management Services .................................... 29
Health Services Management & Delivery ........................................................ 31
Quality Improvement Program (QIP) ............................................................... 33
Marketing .......................................................................................................... 33
Eligibility, Enrollment, and Disenrollment ....................................................... 37
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3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.22
3.23
3.24
3.25
3.26
3.27
4
Working Aged Membership ............................................................................. 39
Claims ............................................................................................................... 40
Communications between MAO and CMS ...................................................... 41
Grievances......................................................................................................... 42
Appeals ............................................................................................................. 43
Health Insurance Portability and Accountability Act of 1996 (HIPAA) .......... 46
Continuation Area ............................................................................................. 47
Part C Application Certification ....................................................................... 47
RPPO Essential Hospital................................................................................... 48
Access to Services (PFFS & MSA) .................................................................. 48
Claims Processing (PFFS & MSA)................................................................... 51
Payment Provisions ........................................................................................... 53
General Administration/Management ............................................................... 54
Document Upload Templates ....................................................... 56
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
History/Structure/Organizational Charts .......................................................... 56
CMS State Certification Form .......................................................................... 58
CMS Provider Contract Required Provision Matrix......................................... 64
CMS Contract Sample Matrix .......................................................................... 69
CMS Administrative Contracting Required Provision Matrix ......................... 70
Part C Application Certification Form .............................................................. 74
RPPO State Licensure Table ............................................................................. 76
RPPO State Licensure Attestation .................................................................... 77
RPPO Essential Hospital Designation Table .................................................... 78
RPPO Essential Hospital Attestation ................................................................ 79
Crosswalk for Part C Quality Improvement Project (QIP) Plan ....................... 80
Crosswalk to Part C Compliance Plan .............................................................. 82
Partial County Justification ............................................................................... 85
Partial County Network Assessment Table ...................................................... 88
5
APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposals
......................................................................................................... 91
6
APPENDIX II: Employer/Union-Only Group Waiver Plans (EGWPs)
MAO “800 Series” ....................................................................... 132
6.1
6.2
6.3
6.4
7
Background ..................................................................................................... 132
Instructions ...................................................................................................... 132
Request for Additional Waivers/Modification of Requirements (Optional) .. 133
Attestations ..................................................................................................... 134
APPENDIX III: Employer/Union Direct Contract for MA.... 139
7.1
7.2
Background ..................................................................................................... 139
Instructions ...................................................................................................... 139
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7.3
7.4
7.5
8
Request for Additional Waivers/Modification of Requirements (Optional) .. 140
Attestations ..................................................................................................... 141
Part C Financial Solvency & Capital Adequacy Documentation For Direct Contract
MAO Applicants: ............................................................................................ 145
APPENDIX IV: Medicare Cost Plan Service Area Expansion
Application ................................................................................... 156
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
State Licensure ................................................................................................ 156
Service Area .................................................................................................... 158
CMS Provider Participation Contracts & Agreements ................................... 158
Contracts for Administrative & Management Services .................................. 160
Health Services Management & Delivery ...................................................... 161
Part C Application Certification ..................................................................... 162
Full Financial Risk .......................................................................................... 162
Budget Forecast .............................................................................................. 162
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1
1.1
GENERAL INFORMATION
Overview
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (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 Medicare Advantage Organizations
(MAOs). The MMA changes make managed care more accessible, efficient, and attractive to
beneficiaries seeking options to meet their needs. The MA program offers several kinds of plans
and health care choices, including Regional Preferred Provider Organizations (RPPOs), Private
Fee-For-Service (PFFS) plans, Special Needs Plans (SNPs), and Medical Savings Account
(MSA) plans.
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
have more information about those choices. The Centers for Medicare & Medicaid Services
(CMS) welcomes organizations that can add value to these programs, make them more
accessible to Medicare beneficiaries, and meet all the contracting requirements.
1.2
Types of MA Products
The MA program is comprised of a variety of product types, including:
•
•
•
•
Coordinated Care Plans (CCPs)
ο Health Maintenance Organizations (HMOs) with or without a Point of Service (POS)
benefit
ο Local Preferred Provider Organizations (LPPOs)
ο Regional Preferred Provider Organizations (RPPOs)
ο Special Needs Plans (SNPs)
Private Fee-for-Service (PFFS) plans
Medical Savings Account (MSA) plans
Employer Group Waiver plans (EGWPs)
Note: For fact sheets on each of these types of product offerings, go to
http://www.cms.gov/HealthPlansGenInfo/
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.
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Note: The MMA requires that CCPs offer at least one MA plan that includes a Part D
prescription drug benefit (MA Part D or MA-PD) in each county of its service area. To meet this
requirement, the Applicant must timely complete and submit a separate Part D application in
connection with this Part C Application.
PFFS plans have the option to offer the Part D drug benefit. MSA plans cannot offer the Part D
drug benefit.
1.3
Important References
MA Organizations
The following are key references about the MA program:
•
•
•
•
Social Security Act: 42 U.S.C 1395 et seq.:
http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
Medicare Regulations: 42 CFR 422:
http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=4b0dbb0c0250d4508a613bbc3d131961&tpl=/ecfrbrowse/Title42/42cfr422_
main_02.tpl
Medicare Managed Care Manual: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html
Marketing Guidelines: http://www.cms.gov/ManagedCareMarketing/
Medicare Cost Plans
Information requested in this application is based on Section 1876 of the Social Security Act
(SSA) and the applicable regulations of Title XIII of the Public Health Services Act.
Additional information can be found on the Centers for Medicare & Medicaid Services (CMS)
Web site: http://www.cms.gov/MedicareCostPlans/
•
•
•
1.4
SSA: 42 U.S.C. 1395mm:
http://www.ssa.gov/OP_Home/ssact/title18/1876.htm
Medicare Regulations: 42 CFR 417:
http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=8072f532d9936eba1bee882c805beedb&tpl=/ecfrbrowse/Title42/42cfr417_
main_02.tpl
Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.gov
Technical Support
CMS 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 are
announced via the HPMS (see section 1.5 below) and/or the CMS main website.
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CMS Central Office (CO) staff and Regional Office (RO) staff are available to provide technical
support to all Applicants during the application process. While preparing the application,
Applicants may email [email protected] . Applicants should contact their RO to
request assistance with specific issues related to their deficiency letters. Below is a list of CMS
RO contacts.
This information is also available at:
https://www.cms.gov/RegionalOffices/
RO I
CMS – BOSTON REGIONAL OFFICE
John F. Kennedy Federal Building, Room 2325, 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: 212-616-2353
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 and West
Virginia
RO IV CMS – ATLANTA REGIONAL OFFICE
Atlanta Federal Center, 61 Forsyth Street, 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 714, 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 Street, Room 235, Kansas City,
MO, 64106
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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 Operations
90 7th Street, Suite 5-300 (5w), San Francisco, CA 94103-6707
Telephone: 415-744-3602
States: Arizona, California, Guam, Hawaii, Nevada, American Samoa and The
Commonwealth Of Northern Mariana Islands
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
For general information about this application, please email: [email protected].
1.5
The Health Plan Management System (HPMS)
A. HPMS is the primary information collection vehicle through which MAOs and Medicare
Cost Plan contractors will communicate with CMS during the application process, bid
submission process, ongoing operations of the MA program or Medicare Cost Plan contracts,
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 must promptly enter organizational data
into HPMS and keep the information up to date. These requirements ensure that CMS has
current information and is able to provide guidance to the appropriate contacts within the
organization. In the event that an Applicant is awarded a contract, this information will also
be used for frequent communications during contract 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 MAOs and Medicare Cost
Plan contractors. This information is then incorporated into the appropriate manuals. It is
imperative for MAOs and Medicare Cost Plan contractors to independently check HPMS
memos and incorporate the guidance as indicated in the memos.
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1.6
Submitting Notice of Intent to Apply (NOIA)
MA Applicants
Organizations interested in offering a new MA product, expanding the service area of an existing
product, or submitting a PFFS network transition application must complete a nonbinding NOIA
by November XX, 20XX. CMS will not accept applications from organizations that fail to
submit a timely NOIA. 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 a 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: https://applications.cms.hhs.gov. Upon approval of the CMS User ID request, the
Applicant will receive a CMS User ID(s) and password(s) for HPMS access. Existing MAO’s
requesting service area expansions do not need to apply for a new contract number.
Medicare Cost Plans
Existing Cost contractors requesting service area expansions should not apply for a new Cost
contract number.
1.7
Additional Information
1.7.A Bid Submission and Training
On or before the first Monday of June of every year, all MAOs and Medicare Cost Plan
contractors offering Part D* 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.
MAOs and Medicare Cost Plan contractors 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 due.
Further instructions and time frames for bid submissions are provided at:
http://www.cms.gov/MedicareAdvtgSpecRateStats/01_Overview.asp#TopOfPage
In order to prepare plan bids, Applicants will use HPMS to define its plan structures, 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 or Medicare Cost Plan benefit and the BPT software to define its
bid pricing information.
Once the PBP and BPT software requirements have been completed for each plan being offered,
Applicants will upload their bids into HPMS. Applicants will be able to submit bid uploads via
HPMS on their PBP or BPT one or more times between May and the CY bid deadline, which is
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the first Monday in June each year. CMS will use the last successful upload received for each
plan as the official bid submission.
CMS will provide technical instructions and guidance upon release of HPMS bid functionality as
well as the PBP and BPT software. In addition, systems training will be available at the Bid
Training in spring 2013.
* Medicare Cost contractors are not required to offer Part D coverage but may elect to do so. A
cost contractor that elects to offer Part D coverage is required to submit a Bid.
1.7.B System and Data Transmission Testing
All MAOs and Medicare Cost Plan contractors must submit information about their membership
to CMS electronically and have the capability to download files or receive electronic information
directly. Prior to the approval of a contract, MAOs and Medicare Cost Plan contractors must
contact the MA Help Desk at 1-800-927-8069 for specific guidance on establishing connectivity
and the electronic submission of files. Instructions are also on the MA Help Desk web page,
https://www.cms.gov/mapdhelpdesk/, in the Plan Reference Guide for CMS Part C/D systems
link. The MA Help Desk is the primary contact for all issues related to the physical submission
of transaction files to CMS.
1.7.C Protecting Confidential Information
Applicants may seek to protect their 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 FOIA
Exemption 4, CMS is required by its FOIA regulation at 45 CFR 5.65(d) and by Executive Order
12600 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; (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 place. Consistent with our approach under other
Medicare programs, CMS would not release information that would be considered proprietary in
nature if the Applicant has shown it meets the requirements for FOIA Exemption 4.
1.7.D Payment Information Form
Please complete the Payment Information form that is located at:
http://www.cms.gov/MedicareAdvantageApps/Downloads/pmtform.pdf.
The document contains financial institution information and Medicare contractor data.
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Please submit the following documents along with the Payment Information form:
•
•
•
•
•
Fax cover sheet that includes the effective month and year
Payment Information Form
Voided Check or confirmation letter from bank
Form must be completely filled out
W-9 Form
If the Applicant has questions about this form, please contact Louise Matthews at (410) 7866903. The completed form needs to be faxed to Louise Matthews at (410) 786-0322.
1.8
Due Date for Applications
MA Plans
Applications must be submitted by 11:59 P.M. EST, February XX, 2013. 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 AND BID REVIEW PROCESS *
Date
Milestone
November 9, 2012
1. Submit NOIA to CMS
2. Request HPMS Access (Includes User ID and Password Request)
3. Request CMS Connectivity
December XX, 2012
CMS User ID form due to CMS
January XX, 2013
February XX, 2013
Final Applications Posted by CMS
Deadline for NOIA form submission to CMS
February XX, 2013
Completed Applications due to CMS
March XX, 2013
Release of Health Plan Management System (HPMS) formulary
submissions module
Plan Creation module, Plan Benefit Package (PBP), and Bid Pricing
Tool (BPT) available on HPMS
April XX, 2013
June 3, 2013
*First Monday in June
All bids due to CMS
September 2013
CMS completes review and approval of bid data. CMS executes MA
and MA-PD contracts with organizations whose bids are approved
and who otherwise meet CMS requirements.
October XX, 2013
Annual Coordinated Election Period begins for CY 2014 plans.
* Note: all dates listed above are subject to change.
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Medicare Cost Plans
Applications must be submitted by 11:59 P.M. EST, February XX, 2013. 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 Medicare Cost Plan application review process:
COST PLAN SAE APPLICATION REVIEW PROCESS *
Date
Milestone
December XX, 2012
1. Submit NOIA to CMS
2. Request HPMS Access (Includes User ID and Password Request)
3. Request CMS Connectivity
CMS User ID form due to CMS
January XX, 2013
February XX, 2013
Final Medicare Cost SAE Application Posted by CMS
Deadline for NOIA form submission to CMS
February XX, 2013
Completed Medicare Cost Plan SAE Application due to CMS
March XX, 2013
Release of Health Plan Management System (HPMS) formulary
submissions module
Plan Creation module, Plan Benefit Package (PBP), and Bid Pricing
Tool (BPT) available on HPMS
November 9, 2012
April XX, 2013
June 3, 2013
All bids due to CMS
*First Monday in June
September 2013
CMS completes review and approval of bid data. CMS executes MA
and MA-PD contracts with organizations whose bids are approved
and who otherwise meet CMS requirements.
October XX, 2013
Annual Coordinated Election Period begins for CY 2014 plans.
* Note: all dates listed above are subject to change.
1.9
Request to Modify a Pending Application
Applicants seeking to withdraw or reduce the service area of a pending application (i.e., one
being reviewed by CMS) must submit a written request to CMS on the organization’s letterhead
and signed by an authorized corporate official. All requests are due to CMS no later than fifteen
days after the issuance of the Notice of Intent to Deny (NOID) letter.
Applicants may submit the request using any of the following methods:
1.
Email - Send the request in PDF format as an attachment to the email message to
[email protected]. Send a copy of the letter via e-mail to the Regional
office Account Manager or Application reviewer.
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2.
Mail – Address the request to:
CMS
Attn: MCAG/DMAO
Mail Stop: C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
Mail a copy of the request to the Regional Office Account Manager or Application
reviewer.
3.
Fax - Send faxed requests to the attention of the Part C Applications Operations Manager
at (410) 786-8933. Fax a copy to the Regional Office Account Manager or Application
reviewer.
The following information must be included in the request:
•
•
•
•
•
Applicant Organization’s Legal Entity Name
Full and Correct Address and Point of Contact information for follow-up, if necessary
Contract Number (H#)
Reason for withdrawal
Exact Description of the Nature of the Withdrawal, for example:
ο Withdrawal from individual Medicare market counties (keeping Medicare employer
group counties, e.g., 800 series plan(s))
ο Withdrawal from employer group counties (keeping the individual Medicare market
counties)
ο Withdrawal of the entire application.
ο Withdrawal of specifically named counties from both individual Medicare and employer
group markets
1.10 Application Determination and Appeal Rights
All Applicants
If CMS determines that the Applicant is not qualified and denies this application, the Applicant
has the right to appeal this determination through a hearing before a CMS Hearing Officer.
Administrative appeals of MA-PD application denials are governed by 42 CFR 422, Subpart N.
The request for a hearing must be in writing, signed by an authorized official of the Applicant
organization, and received by CMS within 15 calendar days from the date CMS notifies the
MAO of its determination (see 42 CFR 422.662.) If the 15th day falls on a weekend or federal
holiday, the Applicant has until the next regular business day to submit its request.
The appealing organization must receive a favorable determination resulting from the hearing or
review as specified under Part 422, Subpart N prior to September XX, 2013 (tentative date) in
order to qualify for a Medicare contract to begin January 1, 2014.
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2
INSTRUCTIONS
2.1
Overview
Applicants must complete the 2014 MA or Medicare Cost Plan application using HPMS as
instructed. CMS will only accept submissions using this current 2013 version 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
certifying that its organization complies with the relevant requirements as of the date the
application is submitted to CMS, unless a different date is stated by CMS.
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
throughout the application process, as well as at any time both prior to and after the start of the
contract year. Failure to meet the requirements represented in this application and to operate MA
or Medicare Cost plans consistent with the applicable statutes, regulations, and the MA or
Medicare Cost Plan contract, and other CMS guidance could result in the suspension of plan
marketing and enrollment. If these issues are not corrected in a timely manner, the Applicant will
be disqualified from participation in the MA or Medicare Cost Plan program, as applicable.
Throughout this application, Applicants are asked to provide various documents and/or tables in
HPMS. There is a summary of all documents required to be submitted at the end of each
attestation section.
CMS strongly encourages MA Applicants to refer to the regulations at 42 CFR 422 while
Medicare Cost Plan Applicants should refer to the regulations at 42 CFR 417 to clearly
understand the nature of the requirements in order to provide an appropriate submission. Nothing
in this application is intended to supersede the regulations at 42 CFR 422 or 42 CFR 417. 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 or 417 of Title 42 of the CFR. Applicants must read HPMS memos and
visit the CMS web site periodically to stay informed about new or revised guidance documents.
2.2
Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans
(EGWPs)
Applicants who wish to offer MA or MA-PD products under Employer/Union-Only Group
Waivers must complete and timely submit a separate EGWP application. Please see APPENDIX
II: Employer/Union-Only Group Waiver Plans (EGWPs) MAO “800 Series” of this application
for details about EGWPs.
All Applicants will be able to enter their EGWP service areas directly into HPMS during the
application process (refer to HPMS User Guide). Applicants may provide coverage to employer
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group members wherever they reside (i.e., nationwide). However, in order to provide coverage to
retirees wherever they reside, Applicants must set their service area to include all areas where
retirees reside during the plan year (i.e., national service areas).
2.3
Applicants Seeking to Offer Employer/Union Direct Contract MAO
Applicants who wish to offer an Employer/Union Direct Contract Private Fee-For Service
(PFFS) MAO must complete and timely submit a separate EGWP application. Please see
APPENDIX III: Employer/Union Direct Contract for MA of this application for details about the
Direct Contract MAO.
In general, MAOs can cover beneficiaries only in the service areas in which they are licensed
and approved by CMS to offer benefits. CMS has waived these requirements for Direct Contract
MAOs. Direct Contract MAO Applicants can extend coverage to all of their Medicare-eligible
active members/retirees regardless of whether they reside in one or more MAO regions in the
nation. In order to provide coverage to retirees wherever they reside, Direct Contract MAO
Applicants must set their service area to include all areas where retirees may reside during the
plan year. CMS will not permit mid-year service area expansions.
Direct Contract MAOs that offer Part D coverage (i.e., MA-PDs) will be required to submit
pharmacy access information for the entire defined service area during the application process
and demonstrate sufficient access in these areas in accordance with employer group waiver
pharmacy access policy.
2.4
Applicants Seeking to Offer Special Needs Plans (SNPs)
New and expanding SNPs must complete and timely submit a separate SNP proposal. Existing
SNPs that require re-approval under the NCQA SNP Approval process should only submit their
Model of Care written narrative and Model of Care Matrix Upload Document. These SNPs will
not be required to submit any other portion of the MA application or SNP proposal, unless
specifically noted (e.g., in the instructions for submission of contracts with State Medicaid
Agencies). Please refer to APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposals
for specific instructions and details.
Existing Dual Eligible SNPs will need to submit a signed and executed State Medicaid Agency
Contract in HPMS without submitting any other portion of the SNP proposal unless the existing
D-SNP is changing its D-SNP subtype or applying for a Service Area Expansion.
2.5
Applicants Seeking to Offer Medicare Cost Plans
All 2014 Applicants seeking to expand the service area of an existing Medicare Cost Plan must
complete and timely submit a separate Medicare Cost Plan application. Please refer to
APPENDIX IV: Medicare Cost Plan Service Area Expansion Application for application
instructions and details.
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2.6
Applicants Seeking to Serve Partial Counties
Applicants seeking to serve less than a full county (i.e., a partial county) must enter all service
area information in HPMS by the application submission deadline, February XX, 2013.
Applicants cannot introduce a partial county request after the initial application submission. In
other words, applicants cannot reduce a full-county request to a partial county request during the
application review period.
2.7
Types of Applications
Initial Applications are for:
•
•
•
Applicants who are seeking an MA contract to offer an MA product for the first time or to
offer an MA product they do not already offer.
Existing MA contractors who are seeking an MA contract to offer a type of MA product they
do not currently offer.
Existing PFFS contractors who are required to transition some or all of their service area to a
network based product.
Note: An RPPO Applicant may apply as a single 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 between/among the member organizations.
Service Area Expansion Applications are for:
•
2.8
Existing MAO contractors who are seeking to expand the service area of an existing contract
number.
Chart of Required Attestations by Type of Applicant
This chart (Chart 1) describes the required attestations that must be completed for each type of
application and Applicant. The purpose of this chart is to provide the Applicant with a summary
of the attestation topics. First, the Applicant must determine if the application will be an initial or
service area expansion type. Then the Applicant must select the type of MA product it will
provide. The corresponding location of each attestation is provided under the column labeled
“Section #,” which corresponds to this application package.
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Chart 1 - Required Attestations by Type of Application
Attestation Topic
Secti
on #
Initial Applicants
PFF
RP
MS
CCP
S
PO
A
Experience and Organizational History
3.1
X
X
X
X
Administrative Management
3.2
X
X
X
X
State Licensure
3.3
X
X
X
X
Program Integrity
3.4
X
X
X
X
Compliance Plan
3.5
X
X
X
X
Key Management Staff
3.6
X
X
X
X
Fiscal Soundness
3.7
X
X
X
X
Service Area
CMS Provider Participation Contracts &
Agreements
Contracts for Administrative & Management
Services
3.8
X
X
X
3.9
X
X
3.10
X
Health Services Management & Delivery
3.11
X
Quality Improvement Program
3.12
Marketing
Service Area Expansion
CC
RP
P
PFFS
PO
MSA
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X*
X
X*
X
X
X
X
3.13
X
X
X
X
Eligibility, Enrollment, and Disenrollment,
3.14
X
X
X
X
Working Aged Membership
3.15
X
X
X
X
Claims
3.16
X
X
X
X
Communications between MAO and CMS
3.17
X
X
X
X
Grievances
3.18
X
X
X
X
Appeals
Health Insurance Portability and Accountability Act
of 1996 (HIPPA)
3.19
X
X
X
X
3.20
X
X
X
X
Continuation Area
3.21
X
X
X
X
X
X
Part C Application Certification
3.22
X
X
X
X
X
X
RPPO Essential Hospital
3.23
Access to Services
3.24
X
·
X
·
Claims Processing
3.25
X
X
X
X
Payment Provisions
3.26
X
X
X
X
General Administration/Management
3.27
X
X
X
X
X
X
X
*Indicates Applicants with a network
·
Indicates that Applicants are not required to complete attestations but must upload selected information, as
required, in HPMS system.
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2.9
Health Services Delivery (HSD) Tables Instructions
Applicants are required to demonstrate network adequacy through the submission of
HSD Tables. Detailed instructions on how to complete each of the required HSD Tables
are available in a separate file along with the HSD Table templates. The HSD instructions
and table templates are available in the MA Download file in HPMS.
As part of the application module in HPMS, CMS will be providing Applicants with an
automated tool for submitting network information via HSD tables. The tables will then
be reviewed automatically against default adequacy measures for each required provider
type in each county. This process will permit Applicants to determine if they have
achieved network adequacy before finalizing their application. Further, CMS will make
these default values known prior to the opening of the application module. As such,
Applicants will see the values (providers and facilities of each required type in each
county) that CMS requires before the application module opens. Applicants who believe
that CMS default values for a given provider type in a given county are not in line with
local patterns of care may seek an exception, in which case the Applicant will submit
required information to support the exception request(s). The HSD exception review will
occur manually by a CMS reviewer as it has in the past. Applicants who submit HSD
tables that 'clear' CMS's default values will still be required to submit signed contracts
and other documents that demonstrate the accuracy of the HSD table submissions.
Applicants may still be determined to have network deficiencies even if they 'pass' the
automated review.
CMS will be providing training to Applicants on the automated system, the HSD
tables, and the default values for determining network adequacy after the application
module opens, and expects to annually post the default values for determining network
adequacy in the Fall of each year.
Application forms and tables associated with the applications are available in separate
Microsoft Word or Excel files that are available at:
http://www.cms.gov/MedicareAdvantageApps/. Microsoft Word files located on the
CMS web site are posted in a .zip format and can also be found in the MA Download file
in HPMS.
Applicants must submit separate completed copies of each table template for each
area/region or county that the Applicant is requesting. Specific instructions on how to
complete and submit each table will be outlined in the 2014 HPMS User Guide for the
Part C Application.
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2.10
Document (Upload) Submission Instructions
MA Applicants must include their assigned H number in the file name of all submitted
documents. Medicare Cost Plan Service Area Expansion Applicants should use their
existing H number in the file name of all submitted documents. Applicants are
encouraged to be descriptive in naming all files. If the Applicant is required to provide
multiple versions of the same document, the Applicant should insert a number, letter, or
even the state name at the end of each file name for easy identification (see the
Application Readme.file).
2.11
MA Part D (MA-PD) Prescription Drug Benefit Instructions
The Part D Application for MA-PD Applicants 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 Part D
Application for MA-PD Applicants 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 Part D Application for MA-PD Applicants can be found at:
http://www.cms.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidanc
e.asp#TopOfPage. Specific instructions to guide MA-PD Applicants in applying to offer
Part D benefits during 2014 are provided in the Part D Application for MA-PD
Applicants and must be followed.
Note: Failure to file the required Part D Application for MA-PD Applicants will render
the MA-PD Application incomplete and could result in the denial of this application.
Failure to submit 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
(NOID) or Denial.
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3 ATTESTATIONS
3.1
Experience & Organization History
The purpose of this section is to allow Applicants to submit information describing their
experience and organizational history. A description of the MAO’s structure of
ownership, subsidiaries, and business affiliations will enable CMS to more fully
understand additional factors that contribute to the management and operation of MA
plans. The following attestations were developed to implement the regulations of 42 CFR
422.502(b) and 422.503(b)
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: EXPERIENCE &
ORGANIZATIONAL HISTORY
YES
NO
1. Is the Applicant applying to be the same type of
organization as indicated on the Applicant’s NOIA? The
Applicant may verify its organization type by looking at
the Contract Management Basic page. If the type of
organization the Applicant’s organization intends to offer
has changed, do not complete this application. Send an
email to [email protected] indicating the
pending contract number and the type of organization for
which the Applicant is now seeking to apply.
2. The Medicare Advantage plan(s) currently offered by the
Applicant, Applicant’s parent organization, or subsidiary
of the Applicant’s parent organization has been operational
since January 1, 2011 or earlier. (If the Applicant,
Applicant’s parent organization, or a subsidiary of
Applicant’s parent organization does not have any existing
contracts with CMS to operate a Medicare Advantage Plan,
select “NA”.)
B. In HPMS, upload the History/Structure/Organizational Charts. This is a brief
summary of the Applicant’s history, structure and ownership. Include organizational
charts to show the structure of ownership, subsidiaries, and business affiliations.
3.2
Administrative Management
The purpose of the administrative management attestations is to ensure that MAOs have
the appropriate resources and structures available to effectively and efficiently manage
administrative issues associated with Medicare beneficiaries. CMS requires that MA
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NA
plans have sufficient personnel and systems to organize, implement, control, and evaluate
financial and marketing activities, oversee quality assurance, and manage the
administrative aspects of the organization. The following attestations were developed to
implement the regulations of 42 CFR 422.503(b)(4)(ii).
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: ADMINISTRATIVE
MANAGEMENT
YES
NO
1. The Applicant has non-renewed its contract with CMS
within the past 2 years.
•
If “Yes”, do not continue and contact CMS
[email protected].
2. The Applicant currently operates a CMS Cost contract
under Section 1876 of the SSA in some or all of the
intended service area of this application.
3. The Applicant offers health plan products to a commercial
population.
4. The Applicant currently has administrative and
management arrangements that feature a policy making
body (e.g., board of directors) exercising oversight and
control over the organization’s policies and personnel (e.g.,
human resources) to ensure that management actions are in
the best interest of the organization and its enrollees.
5. The Applicant currently has administrative and
management agreements that feature personnel systems
sufficient for the organization to organize, implement,
control and evaluate financial and marketing activities,
quality assurance, and the administrative aspects of the
organization.
6. The Applicant currently has administrative and
management agreements that feature an executive manager
/ chief executive officer whose appointment and removal
are under the control of the policy-making body.
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3.3
State Licensure
To ensure that all MAOs operate in compliance with state and federal regulations, CMS
requires MAOs to be licensed under state law. This requirement will ensure that MAOs
adhere to state regulations aimed at protecting Medicare beneficiaries. The following
attestations were developed based on the regulations at 42 CFR 422.400.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: STATE LICENSURE
YES
NO
N/A
1. Applicant is licensed under state law as a riskbearing entity eligible to offer health insurance or
health benefits coverage in each state in which the
Applicant proposes to offer the managed care
product. In addition, the scope of the license or
authority allows the Applicant to offer the type of
managed care product that it intends to offer in
the state or states.
•
If “Yes”, upload in HPMS an executed
copy of a state licensing certificate and the
CMS State Certification Form for each
state being requested.
•
Note: Applicant must meet and document
all applicable licensure and certification
requirements no later than the Applicant’s
final upload opportunity, which is in
response to CMS’ NOID communication.
2. Applicant is a Joint Enterprise.
•
If “Yes”, upload the copy of the Joint
Enterprise agreement executed by the statelicensed entities.
3. Applicant is licensed under state law as a riskbearing entity eligible to offer health insurance or
health benefits in at least one state in the RPPO
region, and if not licensed in all states, the
Applicant has applied for additional state licenses
for the remaining states in the RPPO regions. In
addition, the scope of the license or authority
allows the Applicant to offer the type of MA plan
that it intends to offer in the state or states.
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: STATE LICENSURE
•
If “Yes”, upload in HPMS an executed
copy of a state licensing certificate and the
CMS State Certification Form for each
state being requested or the RPPO State
Licensure Attestation for MA RPPOs and a
complete RPPO State Licensure Table for
each MA Region, if Applicant is not
licensed in all states within the region.
•
Note: Applicant must meet and document
all applicable licensure and certification
requirements no later than the Applicant’s
final upload opportunity, which is in
response to CMS’ NOID communication.
YES
NO
N/A
•
Note: Joint Enterprise Applicants must
submit state certification forms for each
member of the enterprise.
4. Applicant is currently under some type of
supervision, corrective action plan or special
monitoring by the state licensing authority in any
state. This means that the Applicant has to
disclose actions in any state against the legal
entity which filed the application.
•
If “Yes”, upload in HPMS an explanation
of the specific actions taken by the state
licensing authority.
5. Applicant conducts business as "doing business
as" (d/b/a) or uses a name different than the name
shown on its Articles of Incorporation.
•
If “Yes”, upload in HPMS a copy of the
state approval for the d/b/a.
6. For states or territories whose license(s) renew
after the first Monday in June, Applicant agrees
to upload into HPMS the renewed license no later
than the final upload. If the renewed license is
not available at that time, applicant agrees to (1)
upload, in place of the license, a copy of its
completed license renewal application or other
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: STATE LICENSURE
YES
NO
N/A
documentation (e.g., invoice from payment of
renewal fee) to show that the renewal process is
being completed in a timely manner, and (2)
electronically send a copy of the renewed license
to the CMS Regional Office Account Manager
promptly upon issuance.
•
Note: If the Applicant does not have a
license that renews after the first Monday
in June, then the Applicant should respond
"N/A".
B. In HPMS, upload an executed copy of the State Licensing Certificate and the CMS
State Certification Form for each state being requested, if Applicant answers “Yes” to
the corresponding question above.
C. In HPMS, upload a copy of the Joint Enterprise agreement executed by the statelicensed entities, if Applicant answers “Yes” to the corresponding question above.
D. In HPMS, upload an executed copy of a State Licensing Certificate and the CMS
State Certification Form for each state being requested, if Applicant answers “Yes” to
the corresponding question above.
E. In HPMS, upload executed copy of the RPPO State Licensure Attestation for MA
RPPOs and a complete RPPO State Licensure Table for each MA Region, if
Applicant is not licensed in all states within the region and answers “Yes” to the
corresponding question above.
F. In HPMS, upload the State Corrective Plans / State Monitoring Explanation (as
applicable), if Applicant answers “Yes” to the corresponding question above.
G. In HPMS, upload the State Approval for d/b/a, if Applicant answers “Yes” to the
corresponding question above.
Note: Federal Preemption Authority – The MMA amended section 1856(b)(3) of the SSA
and significantly broadened the scope of Federal preemption of state law. The revised
MA regulations’ at 42 CFR 422.402 states that MA standards supersede state law or
regulation with respect to MA plans other than licensing laws and laws relating to plan
solvency.
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3.4
Program Integrity
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: BUSINESS INTEGRITY
1. Applicant, Applicant staff, and its affiliated companies,
subsidiaries or subcontractors (first tier, downstream, and
related entities), and subcontractor staff agree that they
are bound by 2 CFR 376 and attest that they are not
excluded by the Department of Health and Human
Services Office of the Inspector General or by the General
Services Administration exclusion lists. Please note that
this includes any member of the board of directors and
any key management or executive staff or any major
stockholder.
3.5
YES
NO
Compliance Plan
The purpose of a compliance plan is to ensure that the MAO, including but not limited to
compliance officers, organization employees, contractors, managers and directors, abides
by all federal and state regulations, standards, and guidelines. To accomplish this
objective, the plan should include the following components: training/education,
communication plan, disciplinary standards, internal monitoring/auditing procedures, etc.
The following information was developed to implement the regulations of 42 CFR
422.503(b)(4)(vi).
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: COMPLIANCE PLAN
YES
NO
1. Applicant has a compliance plan that is ready for
implementation.
B. If you are applying as a MA-only non-network organization (i.e. PFFS or MSA), in
HPMS, upload a copy of the Applicant’s Medicare Part C Compliance Plan in an
Adobe.pdf format.
Note: The Part C compliance plan must be developed in accordance with 42 CFR
422.503(b)(4)(vi). The compliance plan must demonstrate that all seven elements
in the regulation and in Chapter 11 of the Medicare Managed Care Manual
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(MMCM) are implemented and specific to the issues and challenges presented by
the Part C program.
C. If you are applying as a MA-only non-network organization (i.e. PFFS or MSA) in
HPMS, complete and upload the Crosswalk for Part C Compliance Plan document.
3.6
Key Management Staff
The purpose of this section is to ensure that qualified staff is available to support the
MAO. An organizational chart showing the relationships of the various departments will
demonstrate that the MAO meets this requirement. The following attestations were
developed to implement the regulations of 42 CFR 422.503(b)(4)(ii).
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: KEY STAFF MANAGEMENT
YES
NO
1. Applicant attests that all staff is qualified to perform their
respective duties.
2. Applicant attests that it has completed the Contact
Management/Information/Data page in HPMS.
Contact
Name/Title
Mailing
Address
Phone/Fax
Numbers
Email
Address
Corporate Mailing
CEO – Sr. Official for Contracting
Chief Financial Officer
Medicare Compliance Officer
Enrollment Contact
Medicare Coordinator
System Contact
Customer Service Operations
Contact
General Contact
User Access Contact
Backup User Access Contact
Marketing Contact
Medical Director
Bid Primary Contact
Payment Contact
HIPAA Security Officer
HIPAA Privacy Officer
CEO- CMS Administrator Contact
Quality Director
B. In HPMS, upload organizational charts showing the relationship of various
departments.
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3.7
Fiscal Soundness
A. In HPMS, complete the table below:
YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: FISCAL SOUNDNESS
YES
NO
1. Applicant maintains a fiscally sound operation and maintains
a positive net worth (Total Assets exceed Total Liabilities).
B. In HPMS, upload the most recent Audited Financial Statement that are available and
the most recent Quarterly NAIC Health Blank or other form of quarterly financials if
the NAIC Health Blank is not required by your state. CMS reserves the right to
request additional financial information as it sees fit to determine if the Applicant is
maintaining a fiscally sound operation.
Note: If the Applicant was not in business in 2011, and has less than six months of
operation in 2012, it must electronically upload the financial information it submitted
to the state at the time the state licensure was requested. If the Applicant has a parent
company, it must submit the parent’s 2012 Audited Financial Statement. If the
parent’s 2012 Audited Financial Statement is not available at the time of the
submission of the application, the Applicant must submit the parent’s 2011 Audited
Financial Statement and the parent’s 2012 Annual NAIC Health Blank or other form
of quarterly financials if the NAIC Health Blank is not required by your State.
3.8
Service Area
The purpose of the service area attestation is to clearly define which areas will be served
by the MAO. A service area for local MA plans is defined as a geographic area composed
of a county or multiple counties, while a service area for MA regional plans is a region
approved by CMS. The following attestation was developed to implement the regulations
of 42 CFR 422.2.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: SERVICE AREA
YES
NO
1. Applicant meets the county integrity rule as outlined in
Chapter 4 of the MMCM and will serve the entire county.
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: SERVICE AREA
•
YES
NO
If "No", complete CMS’ Partial County Justification
document.
Note: Applicant may only designate or request a partial county service area during the
initial application submission.
B. In HPMS, on the Contract Management/Contract Service Area/Service Area Data
page, enter the state and county information for the area the Applicant proposes to
serve. Applicants that answered “No” to question 1 above must complete CMS’
Partial County Justification document and Partial County Network Assessment Table.
3.9
CMS Provider Participation Contracts & Agreements
This section contains attestations that address the requirements of 42 CFR 422.504,
which require that MAOs have oversight for contractors, subcontractors, and other
entities. The intent of the regulations is to ensure services provided by these parties meet
contractual obligations, laws, regulations, and CMS instructions. The MAO is held
responsible for the compliance of its providers and subcontractors with all contractual,
legal, regulatory, and operational obligations. Beneficiaries shall be protected from
payment or fees that are the obligation of the MAO. Further guidance is provided in
Chapter 11 of the MMCM.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: PROVIDER CONTRACTS AND
AGREEMENTS
YES
NO
1. Applicant agrees to comply with all applicable provider
requirements in subpart E of this part, including provider
certification requirements, anti-discrimination requirements,
provider participation and consultation requirements, the
prohibition on interference with provider advice, limits on
provider indemnification, rules governing payments to
providers, and limits on physician incentive plans. 42 CFR
422.504(a)(6)
2. Applicant agrees that all provider and supplier contracts or
agreements contain the required contract provisions that are
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: PROVIDER CONTRACTS AND
AGREEMENTS
3.
4.
5.
6.
7.
YES
NO
described in the CMS Provider Contract Required Provision
Matrix, the Medicare Managed Care Manual, and CMS
regulations at 42 CFR 422.504.
Applicant has executed provider, facility, and supplier
contracts in place to demonstrate adequate access and
availability of covered services throughout the requested
service area.
Applicant agrees to have all provider contracts and/or
agreements available upon request.
Applicant has executed CMS Medicare Advantage Contract
Amendments with ALL of its contracted providers and
facilities first tier contracts and downstream contracts at every
level
Applicant has executed CMS Medicare Advantage Contract
Amendments with SOME of its contracted providers and
facilities (first tier contracts and downstream contracts).
Applicant has executed CMS Medicare Advantage Contract
Amendments with NONE of its contracted providers and
facilities (first tier contracts and downstream contracts).
* NOTE: The CMS Medicare Advantage Contract Amendment is the model amendment
released by CMS on September XX, 2012.
B. In HPMS, upon request, upload a completed “CMS Contract Sample Matrix,” the
“CMS Provider Contract Required Provision Matrix” and the provider contracts that
CMS will name during the application review process. These documents and the
contract sample are not required for the initial application submission.
Note: 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.
3.10 Contracts for Administrative & Management Services
This section describes the requirements the Applicant must demonstrate to ensure that
any contracts for administrative/management services comply with the requirements of
all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR
422.504(i)(4)(v). Further guidance is provided in Chapter 11 of the MMCM.
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A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: CONTRACTS FOR ADMINISTRATIVE
MANAGEMENT SERVICES
YES
NO
1. Applicant has contracts with related entities, contractors and
subcontractors (first tier, downstream, and related entities) to
perform, implement or operate any aspect of MA operations
for the MA contract.
2. Applicant verifies that it has entered accurate information
related to the delegated entities and their functions in the
HPMS Delegated Business Function Table in HPMS.
3. Applicant agrees that as it implements, acquires, or upgrades
health information technology (HIT) systems, where
available, the HIT systems and products will meet standards
and implementation specifications adopted under section
3004 of the Public Health Services Act as added by section
13101 of the American Recovery and Reinvestment Act of
2009, P.L. 111-5.
4. Applicant agrees that all contracts for administrative and
management services contain the required contract provisions
that are described in the CMS Administrative Contract
Required Provision Matrix, the MMCM, and the CMS
contract requirements in accordance with 42 CFR 422.504.
5. Applicant has submitted and received CMS approval for an
initial or service area expansion application during at least
one of the past two (2) Medicare Advantage application
review cycles.
B. In HPMS, complete the Delegated Business Function Table under the Part C Data
Link.
Note: If the Applicant plans to delegate a specific function but cannot at this time
name the entity with which the Applicant will contract, enter "Not Yet Determined"
so that CMS is aware of the Applicant’s plans to delegate that function. If the
Applicant delegates a particular function to a number of different entities (e.g., claims
processing to multiple medical groups), then list the five most significant entities for
each delegated business function identified and in the list for the sixth, enter
"Multiple Additional Entities".
C. In HPMS, upload a completed CMS Administrative Contract Required Provision
Matrix.
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D. In HPMS, upload executed management contracts or letters of agreement for each
contractor or subcontractor (first tier, downstream, and related entities). If the
Applicant has received a Part C application approval, initial or SAE, from CMS
during one or both of the two most recent application review cycles (refer to
Attestation #5), then no administrative contract upload is necessary.
3.11 Health Services Management & Delivery
The purpose of the Health Service Management and Delivery attestations is to ensure that
all Applicants deliver timely and accessible health services for Medicare beneficiaries.
CMS recognizes the importance of ensuring continuity of care and developing policies
for medical necessity determinations. Therefore, MAOs will be required to select,
evaluate, and credential providers that meet CMS’ standards, in addition to ensuring the
availability of a range of providers necessary to meet the health care needs of Medicare
beneficiaries. The following attestations were developed to implement the regulations of
42 CFR 422.112, and 422.114.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: HEALTH SERVICES
MANAGEMENT AND DELIVERY
YES
NO
1. Applicant agrees to establish, maintain, and monitor the
performance of a comprehensive network of providers to
ensure sufficient access to Medicare covered services as
well as supplemental services offered by the MAO in
accordance with written policies, procedures, and
standards for participation established by the MAO.
Participation status will be revalidated at appropriate
intervals as required by CMS regulations and guidelines.
2. Applicant has executed written agreements with providers
(first tier, downstream, or other entity instruments)
structured in compliance with CMS regulations and
guidelines.
3. Applicant, through its contracted or deemed participating
provider network, along with other specialists outside the
network, community resources or social services within the
MAO’s service area, agrees to provide ongoing primary
care and specialty care as needed and guarantee the
continuity of care and the integration of services through:
a. Prompt, convenient, and appropriate access to
covered services by enrollees 24 hours a day, 7
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: HEALTH SERVICES
MANAGEMENT AND DELIVERY
YES
NO
days a week;
b. The coordination of the individual care needs of
enrollees in accordance with policies and
procedures as established by the Applicant;
c. Enrollee involvement in decisions regarding
treatment, proper education on treatment options,
and the coordination of follow-up care;
d. Effectively addressing and overcoming barriers to
enrollee compliance with prescribed treatments and
regimens; and
e. Addressing diverse patient populations in a
culturally competent manner.
4. Applicant agrees to establish policies, procedures, and
standards that:
a. Ensure and facilitate the availability, convenient
and timely access to all Medicare covered services
as well as any supplemental services offered by the
MAO;
b. Ensure access to medically necessary care and the
development of medically necessary individualized
care plans for enrollees;
c. Promptly and efficiently coordinate and facilitate
access to clinical information by all providers
involved in delivering the individualized care plan
of the enrollee;
d. Communicate and enforce compliance by providers
with medical necessity determinations; and
e. Do not discriminate against Medicare enrollees.
5. Applicant has verified that contracted providers included
in the MA Facility Table are Medicare certified and the
Applicant certifies that it will only contract with Medicare
certified providers in the future.
6. Applicant agrees to provide all services covered by
Medicare Part A and Part B and to comply with CMS
national coverage determinations, general coverage
guidelines included in Original Medicare manuals and
instructions, and the written coverage decisions of local
Medicare contractors with jurisdiction for claims in the
geographic service area covered by the MAO.
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B. In HPMS, upload the following completed HSD tables:
•
•
MA Provider Table
MA Facility Table
3.12 Quality Improvement Program (QIP)
The purpose of this section is to ensure that all Applicants have a QIP. A QIP will ensure
that MAOs have the infrastructure available to increase quality, performance, and
efficiency of the program on an on-going basis, and will help identify actual or potential
triggers or activities for the purpose of mitigating risk and enhancing patient safety. This
process will provide MAOs an opportunity to resolve identified areas of concern. The
following attestations were developed to implement the regulations of 42 CFR 422.152
and Chapter 5 of the MMCM.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: QIP
YES
NO
1. Applicant has an ongoing QIP that is ready for
implementation. 42 CFR 422.152(a)
2. Applicant agrees to provide CMS with all documents
pertaining to the QIP upon request.
B. In HPMS, upload a copy of the Applicant’s QIP Plan in an Adobe.pdf format.
C. In HPMS, complete and upload the Crosswalk for Part C QIP Plan.
3.13 Marketing
The purpose of the Medicare Operations Marketing attestations is to ensure that all
Applicants comply with all CMS regulations and guidance including, but not limited to,
the Managed Care Manual, user guides, the annual Call Letter, and communications
through HPMS. Medicare Advantage MA and Cost Plans are required to provide
comprehensive information in written form and via a call center to ensure that Medicare
beneficiaries understand the features of their MA plans. The following attestations were
developed to implement the regulations of 42 CFR 422.2260 through 422.2276.
A. In HPMS, complete the table below:
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS
– MARKETING
YES
NO
1. Applicant complies with marketing guidelines and approval
procedures that are contained with Chapter 3 of the Medicare
Managed Care Manual and posted on the www.cms.gov/
website, including the requirements of the File and Use
Certification process.
2. Applicant agrees to make available to beneficiaries those
marketing materials, notices, and other standardized letters and
forms that comply with CMS marketing requirements.
3. Annually and at the time of enrollment, the Applicant agrees to
provide enrollees information about the following features, as
described in the marketing guidelines:
• Enrollment Instruction Forms (Enrollment Kit-at the time
of enrollment)
• Beneficiary Procedural Rights
• Potential for Contract Termination
• Summary of Benefits (Enrollment Kit-at the time of
enrollment and upon request)
• Annual Notice of Change (ANOC)/Evidence of Coverage
(EOC)
• Premiums
• Service Area
• Provider Directory
• Plan ratings information
• Membership ID Card (required at the time of enrollment
and as needed or required by plan sponsor post-enrollment)
4. Applicant agrees to provide general coverage information, as
well as information concerning utilization, grievances, appeals,
exceptions, quality assurance, and financial information to any
beneficiary upon request.
5. The Applicant agrees to verify the identity of the caller as a
beneficiary or validate the authority of the caller to act on
behalf of the beneficiary prior to discussing any Personal
Health Information as required under HIPAA.
6. Applicant agrees to maintain a toll-free customer service call
center that provides customer telephone service to current and
prospective enrollees in compliance with CMS standards. This
means the Applicant complies with the following:
•
Call center operates during normal business hours, seven
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N/A
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS
– MARKETING
YES
NO
days a week from 8:00 AM to 8:00 PM for all time zones
of the Applicants respective service areas.
•
A customer service representative is available to answer
beneficiary calls directly during the annual enrollment and
45 days after the annual enrollment period.
•
On Saturdays, Sundays, and holidays, from February 15th
until the following annual enrollment period, a customer
service representative or an automated phone system may
answer beneficiary calls.
•
If a beneficiary is required to leave a message in voice mail
box due to the utilization of an automated phone system,
the applicant ensures that a return call to a beneficiary is
made in a timely manner, but no more than one business
day after receipt of the message.
•
Call center must provide interpreter service to all nonEnglish speaking, or limited English proficient (LEP)
beneficiaries.
7. Applicant agrees to provide Toll Free TTY or TDD numbers
for all hearing impaired beneficiaries in conjunction with all
other phone numbers utilized for call center activity.
8. Applicant agrees to make the marketing materials specified by
CMS available in any language that is the primary language of
at least 5% of a plan sponsor’s benefit package service area.
NOTE: Plan sponsors operating in service areas that do not
meet the 5% threshold are not required to produce any
translated materials.
9. The Applicant agrees to operate a toll-free call center to
respond to physicians and other providers requesting
exceptions, coverage determinations, prior authorizations, and
beneficiary appeals. This mean the Applicant complies with
the following:
•
The call center must be available to callers from 8:00 am to
6:00 pm, consistent with the local time zone of each of the
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N/A
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS
– MARKETING
YES
NO
Applicant’s respective service areas, Monday through
Friday, at a minimum.
•
An alternative technology, such as an interactive voice
response system or voice mail, may be used outside of
these hours, ensuring that information may be submitted
for action by the Applicant 24 hours a day, 7 days a week.
10. The Applicant agrees to comply with CMS performance
requirements for all call centers including:
•
The average hold time for a beneficiary to reach a customer
service representative is two minutes or less.
•
Eighty percent (80%) of all incoming calls are answered
within 30 seconds.
•
The disconnect rate for all incoming customer calls does
not exceed 5%.
•
Acknowledgement of all calls received via an alternative
technology within one business day.
11. Applicant agrees to guarantee that all call center staff are
effectively trained to provide thorough, accurate, and specific
information on all product offerings, including applicable
eligibility requirements, cost sharing amount, premiums, and
provider networks.
12. Applicant agrees to implement and maintain an explicit
process for handling customer complaints.
13. Applicant agrees to develop and maintain an Internet Web site
providing thorough, accurate, and specific information as
specified by CMS.
14. Applicant agrees to provide initial and renewal compensation
to a broker or agent for the sale of a Medicare health plan
consistent with CMS requirements.
15. Applicant agrees that brokers and agents selling Medicare
products are trained and tested, annually, on Medicare rules
and regulations and the specifics of the plans they are selling,
and that they pass with a minimum score as specified in CMS
guidance.
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N/A
3.14 Eligibility, Enrollment, and Disenrollment
This section identifies attestations consistent with the requirements of 42 CFR 422.50
through 422.74, which address the eligibility requirements to enroll in, continue
enrollment in, or disenroll from an MA plan. The intent of these regulations is to ensure
that all MAOs fully comply with the requirements set forth to ensure services adhere to
standard processes and meet contractual obligations, laws, regulations and CMS
instructions.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS
– ELIGIBILITY, ENROLLMENT and DISENROLLMENT
1. Applicant agrees to comply with all CMS regulations and
guidance pertaining to eligibility, enrollment and
disenrollment for MA, including, but not limited to, the
MMCM, user guides, the annual Call Letter, and interim
guidance and other communications distributed via HPMS.
2. Applicant agrees to provide required notices to
beneficiaries, including pre-enrollment and postenrollment materials, consistent with CMS rules,
guidelines, and regulations, including, but not limited to,
the Annual Notice of Change (ANOC) /Summary of
Benefits (SB)/Evidence of Coverage (EOC), Provider
Directories, Enrollment and Disenrollment notices,
Coverage Denials, ID card, and other standardized and/or
mandated notices.
3. Applicant agrees to accept enrollment elections during
valid election periods from all MA eligible Medicare
beneficiaries who reside in the MA service area, as
provided in Chapter 2 of the MMCM.
4. Applicant agrees to accept responsibility for accurately
determining the eligibility of the beneficiary for
enrollment, as described in Chapter 2 of the MMCM.
5. Applicant agrees to accept responsibility for determining
that a valid election period exists, permitting the
beneficiary to request enrollment in the MAO’s product,
and will accept voluntary disenrollments only during
timeframes specified by CMS.
6. Applicant agrees to collect and transmit data elements
specified by CMS for the purposes of enrolling and
disenrolling beneficiaries in accordance with the CMS’
Eligibility, Enrollment and Disenrollment Guidance.
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NO
Page 37 of 162
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS YES
– ELIGIBILITY, ENROLLMENT and DISENROLLMENT
7. Applicant agrees to ensure that enrollee coverage in the
plan begins as of the effective date of enrollment in the
plan, consistent with the detailed procedures described in
the CMS enrollment guidance. Organizations may not
delay enrollment or otherwise withhold benefits while
waiting for successful (i.e., accepted) transactions to/from
MARx.
8. Applicant agrees to develop, operate and maintain viable
systems, processes, and procedures for the timely,
accurate, and valid enrollment and disenrollment of
beneficiaries in the MAO, consistent with all CMS
requirements, guidelines, and regulations.
9. In the event of contract termination, Applicant will notify
enrollees of termination and of alternatives for obtaining
other MA coverage, as well as Medicare prescription drug
coverage, in accordance with Part 422 and Part 423
regulations.
10. Applicant agrees to establish business processes and
communication protocols for the prompt resolution of
urgent issues affecting beneficiaries, such as late changes
in enrollment or co-pay status, in collaboration with CMS.
11. Applicant acknowledges that enrollees can make
enrollment changes, during election periods for which they
are eligible, in the following ways: A) Electing a different
MA plan by submitting an enrollment request to that
MAO, B) Submitting a request for disenrollment to the
MAO in the form and manner prescribed by CMS.
12. Applicant agrees to perform the following functions upon
receipt of an enrollee’s request for voluntary
disenrollment:
• Submit a disenrollment transaction to CMS within
timeframes specified by CMS.
• Provide enrollee with notice to acknowledge
disenrollment request in a format specified by
CMS.
• File and retain disenrollment requests for the period
specified in CMS instructions, and
• In cases where lock-in applies, include in the notice
a statement explaining that
ο The member remains enrolled until the effective
date of disenrollment
ο Until the effective date of disenrollment (except
for urgent and/or emergent care) neither the
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICARE OPERATIONS YES
– ELIGIBILITY, ENROLLMENT and DISENROLLMENT
MAO nor CMS will pay for services that have
not been provided or arranged for by the MAO
prior to voluntary disenrollment.
13. Applicant will comply with all standards and requirements
regarding involuntary disenrollment of an individual
initiated by the MAO for any circumstances listed below:
• Any monthly plan premiums are not paid on a
timely basis, subject to the grace period for late
payment.
• Individual has engaged in disruptive behavior.
• Individual provides fraudulent information on his
or her election form or permits abuse of his or her
enrollment card.
14. If the Applicant disenrolls an individual for the reasons
stated above, Applicant agrees to give the individual
required written notice(s) of disenrollment with an
explanation of why the MAO is planning to disenroll the
individual. Notices and reason must:
• Be provided to the individual before submission of
the disenrollment to CMS.
• Include an explanation of the individual's right to a
hearing under the MAO's grievance procedure.
15. Applicant acknowledges and commits to utilizing HPMS
as the principle tool for submitting and receiving formal
communications related to MAO performance, enrollee
inquiries (CTM), notices and memoranda from CMS staff,
routine reporting, and the fulfillment of other functional
and regulatory responsibilities and requirements, including,
but not limited to, the submission of marketing materials,
applications, attestations, bids, contact information, and
oversight activities.
16. On a monthly basis, Applicant agrees to accurately and
thoroughly process and submit the necessary information
to validate enrollment in support of the monthly payment,
as provided under 42 CRF 422 subpart G.
NO
3.15 Working Aged Membership
The purpose of these attestations is to ensure that Applicants report all working aged
members to CMS, as well as to identify amounts payable, coordinate benefits to
enrollees, and identify primary Medicare patients. The following attestations were
developed to implement the regulations of 42 CFR 422.108.
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A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: WORKING AGED
MEMBERSHIP
YES
NO
A. Applicant agrees to identify, document, and report to CMS
relevant coverage information for working aged, including:
• Identify payers that are primary to Medicare
• Identify the amounts payable by those payers
• Coordinate the Applicant’s benefits or amounts
payable with the benefits or amounts payable by the
primary payers.
3.16 Claims
The purpose of these attestations is to ensure that the Applicant properly dates and
processes all claims, per CMS instructions listed herein. These attestations also provide
the Applicant with general guidance on how to appropriately notify beneficiaries of claim
decisions. The following attestations were developed to implement the regulations of 42
CFR 422.504(c) and 42 CFR 422.520(a).
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: CLAIMS
YES
NO
1. Applicant agrees to date stamp all claims as they are
received, whether in paper form or via electronic
submission, in a manner that is acceptable to CMS.
2. Applicant will ensure that all claims are processed
promptly and in accordance with CMS regulations and
guidelines.
3. Applicant agrees to give the 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.
4. Applicant agrees to comply with all applicable standards
and requirements and establish meaningful procedures for
the development and processing of all claims, including
having an effective system for receiving, controlling, and
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: CLAIMS
YES
NO
processing claims actions promptly and correctly.
5. Applicant agrees to use an automated claims system that
demonstrates the ability to accurately and timely pay
contracted and non-contracted providers according to CMS
requirements.
3.17 Communications between MAO and CMS
CMS is committed to ensuring clear communications with MAOs. The purpose of this
section is to ensure that all Applicants engage in effective and timely communications
with CMS. Such communications will help improve and support administrative
coordination between CMS and MAOs. The following attestations were developed to
implement the regulations of 42 CFR 422.504(b).
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: COMMUNICATIONS
YES
NO
1. Applicant agrees to facilitate the provision of access to and
assignment of User IDs and Passwords for CMS systems
applications for all key functional, operational, and regulatory
staff within the MAO to ensure the timely completion of
required transactions within the CMS systems structure,
including HPMS, MARx and any other online application
with restricted access.
2. Applicant acknowledges and commits to utilizing HPMS as
the principle tool for submitting and receiving formal
communications related to MAO performance, enrollee
inquiries (CTM), notices and memoranda from CMS staff,
routine reporting, and the fulfillment of other functional and
regulatory responsibilities and requirements including, but not
limited to, the submission of marketing materials,
applications, attestations, bids, contact information, and
oversight activities.
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: COMMUNICATIONS
YES
NO
3. Applicant agrees to establish connectivity to CMS via the
AT&T Medicare Data Communications Network (MDCN) or
via the Gentran Filesaver.
4. Applicant agrees to submit test enrollment and disenrollment
transmissions.
5. Applicant agrees to submit enrollment, disenrollment and
change transactions to CMS within 7 calendar days to
communicate membership information to CMS each month.
6. Applicant agrees to reconcile MA data to CMS
enrollment/payment reports within 45 days of availability.
7. Applicant agrees to submit enrollment/payment attestation
forms within 45 days of CMS report availability.
8. Applicant agrees to ensure that enrollee coverage in the plan
begins as of the effective date of enrollment in the plan,
consistent with the detailed procedures described in the CMS
enrollment guidance. Organizations may not delay enrollment
or otherwise withhold benefits while waiting for successful
(i.e. accepted) transactions to/from MARx.
3.18 Grievances
CMS is committed to guaranteeing that Medicare beneficiaries have access to, education
on, decision making authority for, and are in receipt of quality health care. To ensure that
beneficiaries have the ability to express their concerns and that those concerns are acted
on promptly, MAOs must have a grievance program structured in compliance with CMS
regulations and guidelines. In this capacity, a grievance is defined as any complaint or
dispute, other than one involving an organization determination, expressing
dissatisfaction with the manner in which a Medicare health plan or delegated entity
provides health care services, regardless of whether any remedial action can be taken.
Enrollees or their representatives may make the complaint or dispute, either orally or in
writing, to a Medicare health plan, provider, or facility. An expedited grievance may also
include a complaint that a Medicare health plan refused to expedite an organization
determination or reconsideration, or invoked an extension to an organization
determination or reconsideration period. In addition, grievances may include complaints
regarding the timeliness, appropriateness, access to, and/or setting of a provided health
service, procedure, or item. Grievance issues may also include complaints that a covered
health service procedure or item during a course of treatment did not meet accepted
standards for delivery of health care.
The following attestations were developed to implement the regulations of 42 CFR
422.561and 42 CFR 422.564.
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A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: GRIEVANCES
YES
NO
1. Applicant agrees to comply with all applicable regulations,
standards, guidelines and/or requirements, establishing
meaningful processes, procedures, and effectively training the
relevant staff and subcontractors (first tier, downstream and
related entities), to accept, identify, track, record, resolve, and
report enrollee grievances within the timelines established by
CMS. An accessible and auditable record of all grievances
received on behalf of the MAO, both oral and written, will be
maintained to include, at a minimum: the receipt date, mode
of submission (i.e. fax, telephone, letter, e-mail, etc.),
originator of grievance (person or entity), enrollee affected,
subject, final disposition, and date of enrollee notification of
the disposition.
2. Applicant agrees to advise all MA enrollees of the definition
of a grievance, their rights, the relevant processes, and the
timelines associated with the submission and resolution of
grievances to the MAO and its subcontractors (first tier,
downstream and related entities) through the provision of
information and outreach materials.
3. Applicant agrees to accept grievances from enrollees at least
by telephone and in writing (including fax).
4. Applicant agrees to inform enrollees of the complaint process
that is available to the enrollee under the Quality
Improvement Organization (QIO) process.
3.19 Appeals
CMS recognizes the importance of the appeals process for both MAOs and Medicare
beneficiaries. The purpose of this section is to ensure that beneficiaries have the
opportunity to submit an appeal. Accordingly, MAOs must have an appeals process
structured in compliance with CMS regulations and guidelines. An appeal is defined as
any of the procedures that deal with the review of adverse organization determinations on
the health care services the enrollee believes he or she is entitled to receive, including
delay in providing, arranging for, or approving the health care services (such that a delay
would adversely affect the health of the enrollee), or on any amounts the enrollee must
pay for a service, as defined under 422.566(b). These procedures include reconsiderations
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by the MAO, and if necessary, an independent review entity, hearings before an
Administrative Law Judge (ALJ), review by the Medicare Appeals Council (MAC), and
judicial review. The following attestations were developed to implement the regulations
of 42 CFR 422.561.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: APPEALS
YES
NO
1. Applicant agrees to adopt policies and procedures for
beneficiary organizational determinations, exceptions, and
appeals consistent with 42 CFR 422, subpart M.
2. Applicant agrees to maintain a process for completing
reconsiderations that includes a written description of how
its organization will provide for standard reconsideration
requests and expedited reconsideration requests, where each
are applicable, and how its organization will comply with
such description. Such policies and procedures will be
made available to CMS on request.
3. Applicant agrees to ensure that the reconsideration policy
complies with CMS regulatory timelines for processing
standard and expedited reconsideration requests as
expeditiously as the enrollee's health condition requires.
4. Applicant agrees to ensure that the reconsideration policy
complies with CMS requirements as to assigning the
appropriate person or persons to conduct requested
reconsiderations.
5. Applicant agrees to ensure that the reconsideration policy
complies with CMS timeframes for forwarding
reconsideration request cases to CMS' independent review
entity (IRE) where the Applicant affirms an organization
determination adverse to the member or as otherwise
required under CMS policy.
6. Applicant agrees to ensure that its reconsideration policy
complies with CMS required timelines regarding
Applicant's effectuation through payment, service
authorization or service provision in cases where the
organization's determinations are reversed in whole or part
(by itself, the IRE, or some higher level of appeal) in favor
of the member.
7. Applicant agrees to make its enrollees aware of the
organization determination, reconsideration, and appeals
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: APPEALS
YES
NO
process through information provided in the Evidence of
Coverage and outreach materials.
8. Applicant agrees to establish and maintain a process
designed to track and address in a timely manner all
organization determinations and reconsideration requests,
including those transferred to the IRE, an Administrative
Law Judge (ALJ) or some higher level of appeal, received
both orally and in writing, that includes, at a minimum:
• Date of receipt
• Date of any notification
• Disposition of request
• Date of disposition
9. Applicant agrees to make available to CMS, upon CMS
request, organization determination and reconsideration
records.
10. Applicant agrees to not restrict the number of
reconsideration requests submitted by or on behalf of a
member.
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3.20 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
1. Applicant complies with all applicable standards,
implementation specifications, and requirements in the
Standards for Privacy of Individually Identifiable Health
Information and Security Standards under 45 CFR Parts
160, 162, and 164.
2. Applicant agrees to encrypt all hard drives and other
electronic storage media, including all removable media,
containing electronic protected health information (PHI).
3. Applicant agrees to have policies addressing the secure
handling of portable media that are accessed or used by the
organization.
4. Applicant complies with all applicable standards,
implementation specifications, and requirements in the
Standard Unique Health Identifier for Health Care
Providers under 45 CFR Parts 160 and 162.
5. Applicant complies with all applicable standards,
implementation specifications, operating rules, and
requirements in the Standards for Electronic Transactions
under 45 CFR Parts 160 and 162.
6. Applicant agrees to accept the monthly capitation payment
consistent with the HIPAA-adopted ASC X12N 820,
Payroll Deducted and Other Group Premium Payment for
Insurance Products (“820”).
7. Applicant agrees to submit the Offshore Subcontract
Information and Attestation for each offshore subcontractor
(first tier, downstream, and related entities) that receive,
process, transfer, handle, store, or access Medicare
beneficiary PHI by the last Friday in September for the
upcoming contract year.
8. Applicant agrees to not use any part of an enrollee’s Social
Security Number (SSN) or Medicare ID Number (i.e.,
Health Insurance Claim Number) on the enrollee’s
identification card.
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3.21 Continuation Area
The purpose of a continuation area is to ensure continuity of care for enrollees who no
longer reside in the service area of a plan and who permanently move into the geographic
area designated by the MAO as a continuation area. A continuation area is defined as an
additional area (outside the service area) within which the MAO offering a local plan
furnishes or arranges to furnish services to its continuation-of-enrollment enrollees.
Enrollees must reside in a continuation area on a permanent basis and provide
documentation that establishes residency, such as a driver’s license or voter registration
card. A continuation area does not expand the service area of any MA local plan. The
following attestations were developed to implement the regulations of 42 CFR 422.54.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: CONTINUATION AREA
YES
NO
1. Applicant agrees to establish a continuation area (outside the
service area) within which the MAO offering a local plan
furnishes or arranges to furnish services to its enrollees that
initially resided in the contract service area.
2. Applicant agrees to submit marketing materials that will
describe the continuation area options.
3. Applicant agrees to make arrangements with providers for
payment of claims for Medicare covered benefits to ensure
beneficiary access to services in the continuation area.
4. Applicant agrees to provide for reasonable cost-sharing for
services furnished in the continuation area. An enrollee's costsharing liability is limited to the cost-sharing amounts required
in the MA local plan's service area (in which the enrollee no
longer resides).
3.22 Part C Application Certification
A. In HPMS, upload a completed and signed Adobe.pdf format copy of the Part C
Application Certification Form.
Note: Once the Part C application is complete, Applicants seeking to offer a Part D plan
must complete the Part D application in HPMS. PFFS and Cost Plan SAE organizations
have the option to offer Part D plans. MSAs are not allowed to offer Part D plans.
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3.23 RPPO Essential Hospital
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: RPPO ESSENTIAL HOSPITAL
YES
NO
1. Applicant is requesting essential hospital designation for noncontracted hospitals.
• If “Yes”, upload in HPMS a completed CMS Essential
Hospital Designation Table and Attestation.
B. In HPMS, upload a completed CMS Essential Hospital Designation Table.
3.24 Access to Services (PFFS & MSA)
The purpose of these attestations is to provide the Applicant with information regarding
the offering of the various PFFS models, including a network, partial network, or nonnetwork PFFS model to its members, as applicable. Additionally, these attestations will
inform the Applicant of the documents and/or information that will need to be uploaded
into HPMS. The following attestations were developed to implement the regulations of
42 CFR 422.114(a)(2)(iii).
Please note that, effective with contract year 2012, Section 1862(d) of the SSA, as
amended by Section 162(a)(1) of MIPPA, requires those PFFS plans operating in “network
areas” to meet the access standards described in section 1852(d)(4)(B) of the Act through
contracts with providers. The list of those areas considered “network areas” for purposes of
the 2013 application and contracting requirements can be found at:
http://www.cms.hhs.gov/PrivateFeeforServicePlans/. CMS will not accept a non-network or
partial network application that includes any of the areas identified as “network areas” in the
referenced document. Furthermore, Applicants wishing to offer both network PFFS products
and non-network or partial network PFFS products must do so under separate contracts.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: ACCESS TO SERVICES
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: ACCESS TO SERVICES
YES
NO
1. Applicant agrees to offer a combination PFFS Model that
meets CMS’ access requirements per 42 CFR
422.114(a)(2)(iii).
•
Note: If the Applicant has established payment rates
that are less than Original Medicare for one or more
categories of Medicare covered services under the
MA PFFS plan, the Applicant must offer a
combination PFFS model.
*This attestation is not applicable to MSA Applicants.
2. Applicant agrees to offer a network PFFS model only per
42 CFR 422.114(a)(2)(ii).
•
Note: If the Applicant has established payment rates
that are less than Original Medicare for all
Medicare covered services under the MA PFFS
plan, then the Applicant must offer a network PFFS
model.
*This attestation is not applicable to MSA Applicants.
3. Applicant agrees to offer a non-network PFFS model only
per 42 CFR 422.114(a)(2)(i).
*This attestation is not applicable to MSA Applicants.
4. If providing a network or partial network PFFS plan,
Applicant has direct contracts and agreements with a
sufficient number and range of providers, to meet the
access standards described in section 1852(d)(i) of the Act.
*This attestation is not applicable to MSA Applicants.
5. If providing a combination network, Applicant is providing
a direct contracted network for the following Medicare
covered services:
DROP DOWN BOX WITH THE FOLLOWING
SERVICES:
• Acute Inpatient Hospital Care
• Diagnostic & Therapeutic Radiology (excluding
mammograms)
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: ACCESS TO SERVICES
YES
NO
• DME/Prosthetic Devices
• Home Health Services
• Lab Services
• Mental Illness – Inpatient Treatment
• Mental Illness – Outpatient Treatment
• Mammography
• Renal Dialysis – Outpatient
• SNF Services
• Surgical Services (outpatient or ambulatory)
• Therapy – Outpatient Occupational/Physical
• Therapy – Outpatient Speech
• Transplants (Heart, Heart and Lung, Intestinal, Kidney,
Liver, Lung, Pancreas)
• Other
• Note: If Applicant selects "Other", upload in HPMS
a thorough description of proposed services,
including rationale for providing a contract network
for the proposed service.
•
If Applicant proposes to furnish certain categories
of service through a contracted network, upload in
HPMS a narrative description of the proposed
network. Please ensure that the categories are
clearly defined in the narrative description.
*This attestation is not applicable to MSA Applicants.
6. Applicant agrees to post the organization's "Terms and
Conditions of Payment" on its website, which describes to
members and providers the plan payment rates (including
member cost sharing) and provider billing procedures.
• Note: Applicant can use CMS model terms and
conditions of payment guidance.
*This attestation is not applicable to MSA Applicants.
7. Applicant agrees to provide information to its members and
providers explaining the provider deeming process and the
payment mechanisms for providers.
*This attestation is not applicable to MSA Applicants.
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NOTE: PFFS Applicants must select the combination PFFS model, the network model or
the non-network model (Attestations #1-3) as appropriate for each type of contract (and
application) they seek. A single contract cannot encompass more than one of these
models.
B. In HPMS, upload a description of Proposed Services for combination networks, if
Applicant selects "Other" for question 5. If Applicant proposes to furnish certain
categories of service through a contracted network, please ensure that the categories
are clearly defined in the narrative description. This upload is required for selected
PFFS Applicants.
C. In HPMS, upload a description of how the Applicant will follow CMS’s national
coverage decisions and written decisions of carriers and intermediaries (LMRP)
throughout the United States (Refer to 42 CFR 422.101 (b)). This upload is required
for PFFS and MSA Applicants.
D. In HPMS, upload a description of how the Applicant’s policies ensure that health
services are provided in a culturally competent manner to enrollees of different
backgrounds. This upload is required for PFFS and MSA Applicants.
3.25 Claims Processing (PFFS & MSA)
The purpose of these attestations is to verify that the Applicant uses a validated claims
system, properly implements the Reimbursement Grid and pays all providers according to
the PFFS plan's terms and conditions of payment. Additionally, upon request, the
Applicant will submit to CMS its complete and thorough Provider Dispute Resolution
Policies and Procedures (P&Ps), bi-weekly reports detailing complaints, and/or bi-weekly
reports detailing appeals and/or claims. The following attestations were developed to
implement the regulations of 42 CFR 422.216.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: CLAIMS PROCESSING
YES
NO
1. Applicant agrees to use a claims system that was
previously tested and demonstrates the ability to accurately
and timely pay Medicare FFS payments.
2. If using a claims system that was not previously validated,
Applicant agrees to provide documentation upon request.
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: CLAIMS PROCESSING
YES
NO
3. Applicant has in place the necessary operational claims
systems, staffing, processes, functions, etc. to properly
institute the Reimbursement Grid and pay all providers
according to the PFFS plan’s terms and conditions of
payment.
*This attestation is not applicable to MSA Plans.
4. Applicant agrees that upon request, it will submit its
complete and thorough Provider Dispute Resolution
Policies and Procedures (P&Ps) to address any written or
verbal provider dispute/complaints, particularly regarding
the amount reimbursed. The availability of these P&Ps
must be disclosed to providers. The Applicant must submit
information on how it has integrated the P&Ps into all staff
training - particularly in Provider Relations, Customer
Service and Appeals/Grievances.
5. Applicant agrees that upon request, it will submit a
biweekly report to the CMS RO Account Manager that
outlines all provider complaints (verbal and written),
particularly where providers or beneficiaries question the
amount paid for six months following the receipt of the
first claim. This report will outline the investigation and
the resolution including the completion of a CMS designed
worksheet.
6. Applicant agrees that upon request, it will submit a
biweekly report to the CMS RO Account Manager that
outlines all beneficiary appeals and/or complaints (verbal
and written) related to claims for the six months following
the receipt of the first claim. This report will outline the
investigation and the resolution including the completion
of CMS designed worksheet.
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3.26 Payment Provisions
This section may be applicable to PFFS & MSA Plans
The purpose of these attestations is to ensure that the Applicant has an appropriate system
in place to properly pay providers and to ensure that enrollees are not being overcharged.
Additionally, it instructs Applicants to upload a Reimbursement Grid in HPMS. The
following attestations were developed to implement the regulations of 42 CFR
422.216(c).
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: PAYMENT PROVISIONS
YES
NO
1. PFFS Plans -- Applicant has a system in place that allows
the Applicant to correctly pay providers who furnish
services to its members the correct payment rate according
to the PFFS plan's terms and conditions of payment (e.g., if
the PFFS plan meets CMS' access requirements by paying
providers at Original Medicare payment rates, then it will
have a system in place to correctly pay at those rates
throughout the United States).
*This attestation is not applicable to MSA Applicants.
2. The Applicant has a system in place to ensure members are
not charged more in cost sharing or balance billing than the
amounts specified in the PFFS plan's terms and conditions
of payment. [Refer to 42 CFR 422.216(c)].
3.
4.
5.
6.
*This attestation is not applicable to MSA Applicants
Applicant agrees that information in the Payment
Reimbursement Grid is true and accurate. (PFFS and MSA
Applicants)
Applicant agrees to ensure that members are not charged
more than the Medicare-allowed charge (up to the limiting
charge for non-Medicare participating providers) when
they receive medical services.
Applicant has a system in place to timely furnish an
advance determination of coverage upon a verbal or
written request by a member or provider.
The Applicant has a system in place to ensure members are
not charged after the deductible has been met. [Refer to 42
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: PAYMENT PROVISIONS
YES
NO
CFR 422.103(c)].
*This attestation is not applicable to PFFS Applicants.
7. Applicant agrees to allow providers to balance bill the
beneficiary up to allowed amount.
• Note: This only applies to Applicants that allow
balance billing.
B. In HPMS, upload a completed Payment Reimbursement grid.
Note: Organization may use any format for the Payment Reimbursement grid that best
outlines the organization’s rates. There is no CMS-prescribed format.
3.27 General Administration/Management
This section is applicable to MSA Applicants
The purpose of these attestations is to ensure that the Applicant is offering Medical
Savings Accounts (MSA) plans that follow requirements set forth in law, regulation and
CMS instructions. The Applicant may establish a relationship with a banking partner and
have a system in place to receive Medicare deposits to MSA plan enrollee accounts. The
following sections of 42 CFR 422 contain provisions that are specific to Medical Savings
Accounts : 422.2, 422.4(a) and (c), 422.56, 422.62(d), 422.100(b)(2), 422.102(b),
422.103, 422.104, 422.111(a), 422.152, 422.252, 422.254(e), 422.256(e), 422.262(b)(2),
422.270(a)(1), 422.304(c)(2), and lastly, 422.314.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICAL SAVINGS
ACCOUNTS (MSA)
YES
NO
1. Applicant is offering network MSA plans that follow the
CCP network model.
2. Applicant is offering network MSA plans that follow the
PFFS network model.
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RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: MEDICAL SAVINGS
ACCOUNTS (MSA)
YES
NO
3. Applicant currently operates a commercial Health Savings
Account (HSA) plan or other type of commercial taxfavored health plan or an MA Medical Savings Account
(MSA) plan.
4. Applicant agrees to serve as the MA MSA Trustee or
Custodian for receiving Medicare deposits to MSA plan
enrollee accounts.
5. Applicant agrees to establish a relationship with a banking
partner that meets the Internal Revenue Service (IRS)
requirements (as a bank, insurance company or other
entity) as set out in Treasury Reg. Secs. 1.408-2(e)(2)
through (e)(5).
• If “Yes”, upload the banking contract in HPMS.
6. Applicant agrees to establish policies and procedures with
its banking partner that include the services provided by
the banking partner, including how members access funds,
how spending is tracked and applied to the deductible, and
how claims are processed.
B. In HPMS, upload the banking contract for review by CMS and the Applicant, if
Applicant answered “Yes” to question 5 above, to ensure that ALL CMS direct and/or
any delegated contracting requirements are included in the contract.
C. In HPMS, upload a description of how the Applicant will track enrollee usage of
information provided on the cost and quality of providers. Be sure to include how the
Applicant intends to track use of health services between those enrollees who utilize
transparency information and those who do not.
D. In HPMS, upload a description of how the Applicant will recover current-year deposit
amounts for members who are disenrolled from the plan before the end of the
calendar year.
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4 Document Upload Templates
4.1
History/Structure/Organizational Charts
Note: CMS REQUESTS THAT YOU LIMIT THIS DOCUMENT TO EIGHT (8) PAGES.
Please Check:
_____New to the MA program (initial application)
_____Cost Plan SAE Application
SECTION 1: All Applicants (new and existing) must complete this section.
1. Please give a brief summary of Applicant’s history.
a. Structure:
b. Ownership:
2. Attach a diagram of Applicant’s structure of ownership.
3. Attach a diagram of the Applicant’s relation to its subsidiaries, as well as its
business affiliations.
SECTION II: Applicants that are new to the MA Program must complete this section.
1. Please provide the date of the company’s last financial audit.
2.
What were the results of that audit?
3. Briefly describe the financial status of the Applicant’s company.
4. Briefly explain the Applicant’s marketing philosophy.
5. Who in the Applicant’s organization can appoint and remove the executive
manager?
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6. Please submit a brief description and/or a flow chart of the Applicant’s claims
processing systems and operations.
7. Please submit a brief description and/or flow chart of the Applicant’s
grievances process.
8. Please provide a brief description and flow chart of the Applicant’s appeals
process.
9. If applicable, please provide the name of the claims systems that Applicant
tested to demonstrate the systems’ ability to pay Medicare FFS payments.
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4.2
CMS State Certification Form
INSTRUCTIONS
(MA State Certification Form)
General:
This form is required to be submitted with all MA applications. The MA Applicant is required to
complete the items above the line (items 1 - 3), then forward the document to the appropriate
State Agency Official who should complete those items below the line (items 4-7). After
completion, the State Agency Official should return this document to the Applicant organization
for submission to CMS as part of its application for a MA contract.
The questions provided must be answered completely. If additional space is needed to respond to
the questions, please add pages as necessary. Provide additional information whenever you
believe further explanation will clarify the response.
The MA State Certification Form demonstrates to CMS that the MA contract being sought by the
Applicant organization is within the scope of the license granted by the appropriate State
regulatory agency, that the organization meets state solvency requirements and that it is
authorized to bear risk. A determination on the organization’s MA application will be based
upon the organization’s entire application that was submitted to CMS, including documentation
of appropriate licensure.
Items 1 - 3 (to be completed by the Applicant):
1. List the name, d/b/a (if applicable) and complete address of the organization that is
seeking to enter into the MA contract with CMS.
2. Indicate the type of license (if any) the Applicant organization currently holds in the
State where the Applicant organization is applying to offer an MA contract.
3. Specify the type of MA contract the Applicant organization is seeking to enter into
with CMS.
New Federal Preemption Authority – The Medicare Modernization Act amended section
1856(b)(3) of the SSA to significantly broaden the scope of Federal preemption of State laws
governing plans serving Medicare beneficiaries. Current law provides that the provisions of Title
XVIII of the SSA supersede State laws or regulations, other than laws relating to licensure or
plan solvency, with respect to MA plans.
Items 4 - 7 (to be completed by State Official):
4. List the reviewer’s pertinent information in the event CMS needs to communicate
with the individual conducting the review at the State level.
5. List the requested information regarding other State departments/agencies required to
review requests for licensure.
6. A. Circle where appropriate to indicate whether the Applicant meets State financial
solvency requirements.
B. Indicate State Agency or Division, including contact name and complete address,
that is responsible for assessing whether the Applicant meets State financial solvency
requirements.
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7. A. Circle where appropriate to indicate whether the Applicant meets State licensure
requirements.
B. Indicate State Agency or Division, including contact name and complete address,
that is responsible for assessing whether the Applicant meets State licensing
requirements.
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MEDICARE ADVANTAGE (MA)
STATE CERTIFICATION REQUEST
MA Applicants should complete items 1-3.
1. MA Applicant Information (Organization that has applied for MA contract(s)):
Name _______________________________________________________________
D/B/A (if applicable) ___________________________________________________
Address _____________________________________________________________
City/State/Zip ________________________________________________________
2. Type of State license or Certificate of Authority currently held by referenced
Applicant: (Circle more than one if entity holds multiple licenses)
● HMO ● PSO ● PPO ● Indemnity ● Other ________
Comments:
3. Type of MA application filed by the Applicant with the Centers for Medicare &
Medicaid Services (CMS): (Circle all that are appropriate)
● HMO ● PPO ● MSA ● PFFS ● Religious/Fraternal
Requested Service Area:
________________________________________________________________
I certify that ____________________’s application to CMS is for the type of MA plan(s) and the
service area(s) indicated above in questions 1-3.
____________________________________
MAO
__________________
Date
____________________________________
CEO/CFO Signature
____________________________________
Title
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(An appropriate State official must complete items 4-7.)
Please note that under section 1856(b)(3) of the SSA and 42 CFR 422.402, other than laws
related to State licensure or solvency requirements, the provisions of title XVIII of the SSA
preempt State laws with respect to MA plans.
4. State official reviewing MA State Certification Request:
Reviewer’s Name
________________________________________________________________
State Oversight/Compliance Officer
________________________________________________________________
Agency Name
________________________________________________________________
Address
________________________________________________________________
Address
________________________________________________________________
City/State
________________________________________________________________
Telephone
________________________________________________________________
E-Mail Address
________________________________________________________________
5. Name of other State agencies (if any) whose approval is required for licensure:
Agency______________________________________________
Contact Person________________________________________
Address______________________________________________
City/State____________________________________________
Telephone____________________________________________
E-Mail Address _______________________________________
6. Financial Solvency:
Does the Applicant organization named in item 1 above meet State financial solvency
requirements? (Please circle the correct response)
● Yes
● No
Please indicate which State Agency or Division is responsible for assessing whether
the named Applicant organization meets State financial solvency requirements.
_______________________________________________________________________
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7. State Licensure:
Does the Applicant organization named in item 1 above meet State Licensure
requirements? (Please circle the correct response)
● Yes
● No
Please indicate which State Agency or Division is responsible for assessing whether
this organization meets State licensure requirements.
_____________________________________________________________________
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State Certification
I hereby certify to the Centers for Medicare & Medicaid Services (CMS) that the above
organization (doing business as (d/b/a) _________________________) is:
(Check one)
________
licensed in the State of ___________ as a risk bearing entity, or
________
authorized to operate as a risk bearing entity in the State of ________________
And
(Check one)
________
is in compliance with State solvency requirements, or
________
State solvency requirement not applicable [please explain below].
By signing the certification, the State of __________ is certifying that the organization is
licensed and/or that the organization is authorized to bear the risk associated with the MA
product circled in item 3 above. The State is not being asked to verify plan eligibility for the
Medicare managed care products(s) or CMS contract type(s) requested by the organization, but
merely to certify to the requested information based on the representation by the organization
named above.
____________________________________
Agency
____________________________________
Signature
____________________________________
Title
__________________
Date
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4.3
CMS Provider Contract Required Provision Matrix
Instructions for CMS Provider Contract Required Provision 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 and in those that link
the identified provider/facility to the Applicant.
Instructions:
1.
Provide in the HPMS, using a PDF format, a separate matrix for each county or
partial county.
2.
At the top of each column enter the name of the provider / facility that CMS has
identified in the contract sample.
3.
Designate if the contract uses the CMS Medicare Advantage Contract
Amendment (released by CMS on [insert date], 2012) with a “(M)” next to the
provider / facility name.
4.
Designate if the provider / facility is a first tier contracted provider with a “(1)”
next to the provider / facility name.
5.
Designate downstream contracts provider(s), group(s), or other entity with a
“(DS)” next to the provider/facility name.
6.
For each provider, in the row listing each requirement, provide the page number
where the provision that meets the regulatory requirement can be found in each of
the contracts / agreements listed.
Note: This matrix contains a brief description of MA regulatory requirements; please refer
to full regulatory citations for an appropriate response.
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CMS Provider Contract Required Provision Matrix
CONTRACT #: _______________
COUNTY: ____________ STATE: _______
IPA/Group/Provider Name
CMS Medicare Advantage Contract Amendment (If yes, enter “M”)
First Tier (Enter “1”) or Downstream (Enter “DS”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
All Provider Contracts
Right to Audit and Records Retention
HHS, the Comptroller General, or their designees have the right to audit,
evaluate, and inspect any pertinent information for any particular contract
period, including, but not limited to, any books, contracts, computer or
other electronic systems (including medical records and documentation of
the first tier, downstream, and entities related to CMS’ contract with the
MA organization) through 10 years from the final date of the contract
period or from the date of completion of any audit, whichever is later.
422.504(i)(2)(i) and (ii)
Confidentiality L/W CMS and Sponsor
Comply with the confidentiality and enrollee record accuracy requirements,
including: (1) abiding by all Federal and State laws regarding
confidentiality and disclosure of medical records, or other health and
enrollment information, (2) ensuring that medical information is released
only in accordance with applicable Federal or State law, or pursuant to
court orders or subpoenas, (3) maintaining the records and information in
an accurate and timely manner, and (4) ensuring timely access by enrollees
to the records and information that pertain to them.
•
In addition to the CFR citations provided above, the following contract provisions are required in agreements between MAOs and
provider and suppliers of health care as stated in Chapter 11, section 100.4, of the MMCM .
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Section/Page
IPA/Group/Provider Name
CMS Medicare Advantage Contract Amendment (If yes, enter “M”)
First Tier (Enter “1”) or Downstream (Enter “DS”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
422.504(a)13 and 422.118
Hold Harmless
Prohibited from holding any enrollee liable for payment of any fees that are
the legal obligation of the MA organization.
422.504(g)(1)(i) and 422.504(i)(3)(i)
Hold Harmless for MAs with Enrollees Eligible for Both Medicare and
Medicaid
For all enrollees eligible for both Medicare and Medicaid, enrollees will not
be held liable for Medicare Part A and B cost sharing when the State is
responsible for paying such amounts. May not impose cost-sharing that
exceeds the amount of cost-sharing that would be permitted with respect to
the individual under Title XIX if the individual were not enrolled in such a
plan. Providers will:
(1) accept the MA plan payment as payment in full, or
(2) bill the appropriate State source.”
422.504(g)(1)(iii)
Consistent and Comply with MAO’s Contractual Obligations
Any services or other activity performed are consistent and comply with the
MA organization’s contractual obligations.
422.504(i)(3)(iii)
Prompt Payment
The MA organization is obligated to pay contracted providers under the
terms of the contract between the MA organization and the provider. The
contract must contain a prompt payment provision, the terms of which are
developed and agreed to by both the MA organization and the relevant
provider.
422.520(b)
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Section/Page
IPA/Group/Provider Name
CMS Medicare Advantage Contract Amendment (If yes, enter “M”)
First Tier (Enter “1”) or Downstream (Enter “DS”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
Delegated Activities: Selection of Providers
If the MAO delegates a selection of providers, written arrangements must
state the MAO retains the right to approve, suspend, or terminate such
arrangement.
422.504(i)(5)
Delegated Activities – List of Delegated Activities and Reporting
Responsibilities
The contract must clearly state the delegated activities and reporting
responsibilities.
422.504(i)(4)(i)
Delegated Activities – Revocation
Agreement provides for the revocation of the delegated activities and
reporting requirements or specifies other remedies in instances when CMS
or the MAO determines that such parties have not performed satisfactorily.
422.504(i)(4)(ii)
Delegated Activities – Monitoring
Agreement provides that the performance of the parties is monitored by the
MAO on an ongoing basis.
422.504(i)(4)(iii)
Delegated Activities - Credentialing
The credentials of medical professionals affiliated with the party or parties
will either be reviewed by the MAO OR the credentialing process will be
reviewed and approved by the MAO and the MAO must audit the
credentialing process on an ongoing basis.
422.504(i)(4)(iv)
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Section/Page
IPA/Group/Provider Name
CMS Medicare Advantage Contract Amendment (If yes, enter “M”)
First Tier (Enter “1”) or Downstream (Enter “DS”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
Compliance with Applicable Medicare Laws and Regulations
Must comply with all applicable Medicare laws, regulations, and CMS
instructions.
422.504(i)(4)(v)
Effective Date of Contract (e.g., January 1, 2014 – December 31, 2014, or
automatic renewal provision)
Right to Amend Contract (e.g., unilateral or by mutual agreement)
Signature and Date Contract Executed
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Section/Page
4.4 CMS Contract Sample Matrix
Instructions: The applicant must submit a completed CMS Contract Sample Matrix to accompany the sample of contracts requested by
CMS. It is CMS' expectation that the applicant submit executed contracts at each level of contracting between the applicant and the actual
provider where the provider is not under direct contract with the applicant. The applicant must also submit a completed CMS Provider
Contract Required Provision Matrix indicating where each of the contracts contains the required contract provisions.
Contract Number:
Organization Name:
Date Submitted:
Name of Provider /
Physician (IPA Medical
Group)
Type of Provider
/ Specialty
Name of Signatory to
Contract (If different
from Provider Name,
explain in Comments
column)
Comments (e.g., Explain if no
provider contract, signatory
different from provider,
relationship between applicant
and provider, etc.)
List all contracts that link the selected
provider / facility to the applicant. After
the provider/facility name, indicate with
an “M” any contracts that use the CMS
Medicare Advantage Contract
Amendment (released by CMS on [insert
date], 2012)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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4.5
CMS Administrative Contracting Required Provision Matrix
Administrative Contracting Requirements for Management/Delegation of
Contracts and/or Agreements
(For contracts and/or agreements that directly relate to MAO’s core functions
under its contract with CMS)
Instructions for CMS Administrative Contract Matrix
MA Applicants must complete this matrix to indicate (by Section/Page) on which
each fully executed administrative contract complies with the required Medicare
provisions as listed in the Matrix. MA Applicants that have received CMS
approval for an application during either of the two most recent application
cycles do NOT need to submit any administrative contracts nor the CMS
Administrative Contract Matrix for this application review.
Instructions:
1 Develop a single matrix for each application contract number.
2 Enter the name of the administrative contractor with which the
Applicant has a fully executed agreement for a core function at the top
of each column.
3 Designate if the contract / agreement uses the CMS Medicare
Advantage Contract Amendment (release by CMS on [insert date,
2012]. If yes, then enter “M.” If not, then leave the cell blank.
4 Enter the section and/or page number within each column on which
that fully executed agreement includes the required Medicare
provision.
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CMS Administrative /Contracting Required Provision Matrix
NAME OF CONTRACTOR (FIRST TIER, DOWNSTREAM and RELATED
ENTITY)
CMS Medicare Advantage Contract Amendment (If Yes, enter “M”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
Record Retention
HHS, the Comptroller General or their designees have the right to audit,
evaluate and inspect any pertinent information including books, contracts,
records, including medical records, and documentation related to CMS’
contract with the MAO for a period of 10 years from the final date of the
contract period or the completion of any audit, whichever is later.
422.504(i)(2)(i) and (ii)
Privacy and Accuracy of Records
Providers and suppliers agree to safeguard beneficiary privacy and
confidentiality and ensure the accuracy of beneficiary health records.
422.504(a)13
Hold Harmless**
Providers may not hold beneficiaries liable for payment of fees that are the
legal obligation of the MAO.
(Does not charge enrollees for any health care or health-care related
services)
422.504(g)(1)(i); 422.504(i)(3)(i)
Delegated Activities: Compliance with MAO’s contractual obligations
A provision requiring that any services performed will be consistent and
2014 Part C Application
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Section/Page
NAME OF CONTRACTOR (FIRST TIER, DOWNSTREAM and RELATED
ENTITY)
CMS Medicare Advantage Contract Amendment (If Yes, enter “M”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
comply with the MAO’s contractual obligations.
422.504(i)(3)(iii)
Delegated Activities: Selection of Providers
If the MAO delegates the selection of providers, written arrangements must
state the MAO retains the right to approve, suspend, or terminate such
arrangement.
422.504(i)(5)
Delegated Activities: List of Delegated Activities and Reporting
Responsibilities
The contract must clearly state the delegated activities and reporting
responsibilities.
422.504(i)(4)(i)
Delegated Activities: Revocation
Agreement provides for the revocation of the delegated activities and
reporting requirements or specifies other remedies in instances when CMS
or the MAO determines that such parties have not performed satisfactorily.
422.504(i)(3)(ii); 422.504(i)(4)(ii)
Delegated Activities: Monitoring
Agreement provides that the performance of the parties is monitored by the
MAO on an ongoing basis.
422.504(i)(3)(ii); 422.504(i)(4)(iii)
Delegated Activities: Credentialing
The credentials of medical professionals affiliated with the party or parties
will either be reviewed by the MAO OR the credentialing process will be
reviewed and approved by the MAO; and the MAO must audit the
credentialing process on an ongoing basis.
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Section/Page
NAME OF CONTRACTOR (FIRST TIER, DOWNSTREAM and RELATED
ENTITY)
CMS Medicare Advantage Contract Amendment (If Yes, enter “M”)
CMS REGULATIONS – 42 CFR 422 •
Section/Page
Section/Page
Section/Page
Section/Page
Section/Page
422.504(i)(4)(iv)(A)(B)
Compliance with Applicable Medicare Laws and Regulations
Must comply with all applicable Medicare laws, regulations, and CMS
instructions.
422.504(i)(4)(v)
Dated and Signed
* In addition to the CFR citations provided above, the following contract provisions are required in agreements between
MAOs and provider and suppliers of health care as stated in Chapter 11, section 100.4 of the MMCM.
**This provision is not required in administrative agreements where the first tier, downstream or related entity does not charge
enrollees for any health care or health-care related services.
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4.6
Part C Application Certification Form
I,
, attest to the following:
(NAME & TITLE)
1. I have read the contents of the completed application and the information contained
herein is true, correct, and complete. If I become aware that any information in this
application is not true, correct, or complete, I agree to notify the Centers for Medicare
& Medicaid Services (CMS) immediately and in writing.
2. I authorize CMS to verify the information contained herein. I agree to notify CMS in
writing of any changes that may jeopardize my ability to meet the qualifications
stated in this application prior to such change or within 30 days of the effective date
of such change. I understand that such a change may result in termination of the
approval.
3. I agree that if my organization meets the minimum qualifications and is Medicareapproved, and my organization enters into a Part C contract with CMS, I will abide
by the requirements contained in Section 3 of this Application and provide the
services outlined in my application.
4. I agree that CMS may inspect any and all information necessary, including inspecting
of the premises of the Applicant’s organization or plan to ensure compliance with
stated Federal requirements, including specific provisions for which I have attested. I
further agree to immediately notify CMS if, despite these attestations, I become aware
of circumstances that preclude full compliance by January 1 of the upcoming contract
year with the requirements stated here in this application as well as in Part 422 of 42
CFR of the regulation.
5. I understand that in accordance with 18 U.S.C. §1001, any omission,
misrepresentation or falsification of any information contained in this application or
contained in any communication supplying information to CMS to complete or
clarify this application may be punishable by criminal, civil, or other administrative
actions including revocation of approval, fines, and/or imprisonment under Federal
law.
6. I further certify that I am an authorized representative, officer, chief executive officer,
or general partner of the business organization that is applying for qualification to
enter into a Part C contract with CMS.
7. I acknowledge that I am aware that there is operational policy guidance, including the
forthcoming Call Letter, relevant to this application that is posted on the CMS
website and that it is continually updated. Organizations submitting an application in
response to this solicitation acknowledge that they will comply with such guidance
should they be approved for a Part C contract.
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Authorized Representative Name (printed)
Title
Authorized Representative Signature
Date (MM/DD/YYYY)
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4.7
RPPO State Licensure Table
Complete a separate table for each MA Region which the Applicant proposes to serve
pursuant to this application. Please make copies as necessary.
Entity Name: ____________________________
MA Region: _____________________________
State
(Two
Letter
Abbrev.)
Is
Applicant
Licensed
in State?
Yes or No
2014 Part C Application
If No, Give
Date
Application
was Filed
with State
Type of License
Held or
Requested
Final
Does State have
Restricted
Reserve
Requirements (or
Legal
Equivalent)? If
Yes, Give
Amount
State Regulator’s
Name, Address
Phone #
Page 76 of 162
4.8
RPPO State Licensure Attestation
By signing this attestation, I agree that the Applicant has applied to be licensed, in each
state of its regional service area(s) in which it is not already licensed, sufficient to
authorize Applicant to operate as a risk bearing entity that may offer health benefits,
including an MA Regional Preferred Provider Organization (RPPO) product.
I understand that, in order to offer an MA RPPO plan, section 1858(d) of the SSA, as
added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(P.L. 108-173), requires an entity to be licensed in at least one state in each of the RPPO
Regions it seeks to cover in order to receive a temporary licensure waiver. This
temporary waiver is to allow for the timely processing, as determined by CMS, of
licensure applications for other states within the requested RPPO Region.
I understand that my organization will be required to provide documentary evidence of its
filing or licensure status for each state of its regional service area(s) consistent with this
attestation. I further understand that CMS may contact the relevant state regulators to
confirm the information provided in this attestation as well as the status of Applicant’s
licensure request(s).
I further agree to immediately notify CMS if, despite this attestation, I become aware of
circumstances that indicate noncompliance with the requirements indicated above.
Name of Organization: ____________________________________________________
Printed Name of CEO: ____________________________________________________
Signature: ____________________________________________________
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4.9
RPPO Essential Hospital Designation 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 SSA 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 SSA. The attestation on the following page must be
completed and submitted with the completed chart.
Hospital name
and address
(including
county)
Contact
person and
phone
Hospital
Type/Pro
vider
Number
Method by which
offer was
communicated
Date(s) offer
refused/how
refused
Happy Care
Medical Center
211 Green St.,
Foxdale,
Delaware
County, PA
21135
Any Body,
CFO
(215) 345-1121
Acute
Care/
210076
2 Letter Offers
followed by 2 phone
calls
Letter dated 8/02/05.
Confirmed by phone
call with CFO
2014 Part C Application
Final
Why hospital is needed to meet
RPPO’s previously submitted access
standards, including distance from
named hospital to next closest
Medicare participating contracted
hospital
Nearest Medicare participating inpatient
facility with which Applicant contracts
is in downtown Philadelphia, PA – 35
or more miles away from beneficiaries
in Delaware County. Applicant’s
hospital access standard is 98% of
beneficiaries in Delaware County and
northern half of Chester County have
access to inpatient facility within 30
miles drive.
Page 78 of 162
4.10 RPPO Essential Hospital Attestation
RPPO Attestation Regarding Designation of “Essential” Hospitals
Applicant Organization named below (the Organization) attests that it made a good
faith effort consistent with Section 1858(h) of the SSA and 42 CFR 422.112(c)(3), to
contract with each hospital identified by the Organization in the attached chart at rates
no less than current Medicare inpatient fee-for-service amounts and that, in each case,
the hospital refused to enter into a contract with the Organization.
CMS is authorized to inspect any and all books or records necessary to substantiate
the information in this attestation and the corresponding designation requests.
The Organization agrees to notify CMS immediately upon becoming aware of any
occurrence or circumstance that would make this attestation inaccurate with respect to
any of the designated hospitals. I possess the requisite authority to execute this
attestation on behalf of the Organization.
Name of Organization: ______________________________________________
Printed Name of CEO: ______________________________________________
Signature:_________________________________________________________
Medicare Advantage RPPO Application/Contract Number(s):
R#_____ ______ ______ ______ ______ ______ ______ ______ ______ ______
Note: This attestation form must be signed by any organization that seeks to
designate one or more hospitals as “essential.”
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4.11 Crosswalk for Part C Quality Improvement Project (QIP) Plan
Crosswalk for Part C QIP Plan
Directions: The purpose of the Crosswalk for Part C QIP Plan is to ensure that the Applicant has a QIP plan that is ready for implementation.
Compliance Plan Element
Reference
Document
42 CFR
Page
Number
SECTION I: QI Program Plan For All Plan Types
A. Chronic Care Improvement Program that includes the following components:
422.1529(a)(1)
422.152(c)
1. Methods for identifying MA enrollees with multiple or sufficiently severe chronic conditions that would benefit from
participating in a chronic care improvement program.
2. Mechanisms for monitoring MA enrollees that are participating in the chronic care improvement program.
B. Narrative about quality improvement projects (QIPs) that can be expected to have a beneficial
422.152(a)(2)
effect on health outcomes and enrollee satisfaction, and include the following components:
422.152(d)
1. Focus on significant aspects of clinical care and non-clinical services that includes the following:
i. Measurement of performance
ii.
System interventions, including the establishment or alteration of practice guidelines
iii. Improving performance
iv. Systematic and periodic follow-up on the effect of the interventions
2. Assessing performance under the plan using quality indicators that are:
i. Objective, clearly and unambiguously defined, and based on current clinical knowledge or health services research
ii.
Capable of measuring outcomes such as changes in health status, functional status and enrollee satisfaction, or
valid proxies of those outcomes
3. Performance assessment on the selected indicators must be based on systematic ongoing collection and analysis of valid
and reliable data.
4. Interventions must achieve demonstrable improvement.
5. The organization must report the status and results of each project to CMS as requested.
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NA
NA
Crosswalk for Part C QIP Plan
Directions: The purpose of the Crosswalk for Part C QIP Plan is to ensure that the Applicant has a QIP plan that is ready for implementation.
Compliance Plan Element
Reference
Document
42 CFR
Page
Number
C. Maintain health information system that collects, analyzes and integrates the data necessary to
422.152(f)(1)(i)
implement the QIP.
D. Mechanism to ensure that all information received from the providers of services is reliable,
422.152(f)(1)(ii-iii)
complete and available to CMS.
E. A process for formal evaluation (at least annually) of the impact and effectiveness of the QIP.
422.152(f)(2)
F. Correction of all problems that come to its attention through internal surveillance, complaints, or
422.152(f)(3)
other mechanisms.
SECTION II: For HMOs and Local PPO (licensed or organized under state law as an HMO) (excluding RPPOs)
G. Mechanism that encourages its providers to participate in CMS and HHS QI initiatives.
422.152(a)(3)
H. Written policies and procedures that reflect current standards of medical practice.
422.152(b)(1)
I. Mechanism to detect both underutilization and overutilization of services.
422.152 (b)(2)
J. Measurement and reporting of performance must include the following components:
422.152 (b)(3)
1. Use the measurement tools required by CMS and report performance.
2. Make available to CMS information on quality and outcomes measures that will enable beneficiaries to compare health
coverage options and select among them.
SECTION III: For Regional PPO and Local PPOs (that are not licensed or organized under state law as an HMO)
K. Use the measurement tools required by CMS and report performance.
422.152 (e)(2)(i)
L. Evaluate the continuity and coordination of care furnished to enrollees.
422.152 (e)(2)(ii)
M. If using written protocols for utilization review, protocols must be based on current standards of
422.152(e)(2)(iii)(B)
medical practice and have a mechanism to evaluate utilization of services and to inform enrollees
and providers of services of the evaluation results.
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4.12 Crosswalk to Part C Compliance Plan
Crosswalk for Part C Compliance Plan
Compliance Plan Element
Reference
42 CFR
A. Written policies, procedures, and standards of conduct that must include the following seven
422.503(b)(4)(vi)(A)
components:
1. Articulate the organization’s commitment to comply with all applicable Federal and State standards.
2. Describe compliance expectations as embodied in the standards of conduct.
3. Implement the operation of the compliance program.
4. Provide guidance to employees and others on dealing with potential compliance issues.
5. Identify how to communicate compliance issues to appropriate compliance personnel.
6. Describe how potential compliance issues are investigated and resolved by the organization.
7. Include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program,
including but not limited to reporting potential issues, investigating issues, conducting self-evaluations, audits and
remedial actions, and reporting to appropriate officials.
B. Designation of a compliance officer and a compliance committee that are accountable to senior
422.503(b)(4)(vi)(B)
management and include the following three components:
1. The compliance officer, vested with the day-to-day operations of the compliance program, must be an employee of the
MAO, parent organization or corporate affiliate. The compliance officer may not be an employee of the MAO’s first tier,
downstream or related entity.
2. The compliance officer and the compliance committee must periodically report directly to the governing body of the
MAO on the activities and status of the compliance program, including issues identified, investigated, and resolved by
the compliance program.
3. The governing body of the MAO must be knowledgeable about the content and operation of the compliance program and
must exercise reasonable oversight with respect to the implementation and effectiveness of the compliance programs.
C. Effective training and education that must include the following two components:
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422.503(b)(4)(vi)(C)
Page 82 of 162
Document
Page
Number
NA
NA
NA
Crosswalk for Part C Compliance Plan
Compliance Plan Element
D.
E.
F.
G.
Reference
42 CFR
1. Implementing an effective training and education between the compliance officer and organization employees, the
MAO’s chief executive or other senior administrator, managers and governing body members, and the MAO’s first tier,
downstream, and related entities. Such training and education must occur annually at a minimum and must be made a
part of the orientation for a new employee, new first tier, downstream and related entities, and new appointment to a
chief executive, manager, or governing body member.
2. First tier, downstream, and related entities who have met the fraud, waste, and abuse certification requirements through
enrollment into the Medicare program are deemed to have met the training and educational requirements for fraud,
waste, and abuse.
Establishment and implementation of effective lines of communication, ensuring confidentiality,
422.503(b)(4)(vi)(D)
between the compliance officer, members of the compliance committee, the MAO’s employees,
managers and governing body, and the MAO’s first tier, downstream, and related entities. Such
lines of communication must be accessible to all and allow compliance issues to be reported,
including a method for anonymous and confidential good faith reporting of potential compliance
issues as they are identified.
Well-publicized disciplinary standards that are enforced and include the following three policies:
422.503(b)(4)(vi)(E)
1. Articulate expectations for reporting compliance issues and assist in their resolution.
2. Identify noncompliance or unethical behavior.
3. Provide for timely, consistent, and effective enforcement of the standards when noncompliance or unethical behavior is
determined.
Establishment and implementation of an effective system for routine monitoring and
422.503(b)(4)(vi)(F)
identification of compliance risks. The system should include internal monitoring and audits and,
as appropriate, external audits, to evaluate the MAO, including first tier entities’ compliance with
CMS requirements and the overall effectiveness of the compliance program.
Establishment and implementation of procedures and a system for promptly responding to
422.503(b)(4)(vi)(G)
compliance issues as they are raised, investigating potential compliance self-evaluations and
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Document
Page
Number
Crosswalk for Part C Compliance Plan
Compliance Plan Element
Reference
42 CFR
audits, correcting such problems promptly and thoroughly to reduce the potential for recurrence,
and ensure ongoing compliance with CMS requirements. The procedures must include the
following components:
1. If the MAO discovers evidence of misconduct related to payment or delivery of items or services under the contract, it
must conduct a timely, reasonable inquiry into that conduct.
2. The MAO must conduct appropriate corrective actions (for example, recoupment of overpayments, disciplinary actions
against responsible employees) in response to the potential violation referenced in paragraph T.
3. The MAO should have procedures to voluntarily self-report potential fraud or misconduct related to the MA program to
CMS or its designee.
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Document
Page
Number
4.13 Partial County Justification
Instructions: MA applicants requesting service areas that include one or more partial
counties must upload a completed Partial County Justification with the MA Application.
Complete and upload a Partial County Justification form for each partial county in your
proposed service area. This form is appropriate for organizations (1) entering into a new
partial county or (2) expanding a current partial county by one or more zip codes when
the resulting service area will continue to be a partial county. In this scenario, the
Justification pertains to the proposed zip codes versus the zip codes already approved by
CMS.
MA applicants expanding from a partial county to a full county do NOT need to submit a
Partial County Justification.
NOTE: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
Using just a few sentences, briefly describe why you are proposing a partial county.
SECTION II: Partial County Requirements
The Medicare Managed Care Manual Chapter 4, Section 150.3 provides guidance on
partial county requirements. The following questions pertain to those requirements; refer
to Section 150.3 when responding to them.
Explain how and submit documentation to show that the partial county meets all three of
the following criteria:
1. Necessary – Check the option(s) that applies to your organization, and provide
documentation to support your selection(s):
You cannot establish a provider network to make health care services
available and accessible to beneficiaries residing in the excluded portion of
the county.
You cannot establish economically viable contracts with sufficient providers
to serve the entire county.
Describe the evidence that you are providing to substantiate the above
statement(s) and (if applicable) attach it to this form:
2. Non-discriminatory – You must be able to substantiate both of the following
statements:
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The racial and economic composition of the population in the portion of the
county you are proposing is comparable to the excluded portion of the county.
Using U.S. census data (or data from another comparable source), compare
the racial and economic composition of the included and excluded portions of
the proposed county service area.
The anticipated health care costs of the portion of the county you are
proposing to serve is similar to the area of the county that will be excluded
from the service area.
Describe the evidence that you are providing to substantiate the above
statement and (if applicable) attach it to this form:
3. In the best interest of beneficiaries – The partial county must be in the best
interest of the beneficiaries who are in the pending service area.
Describe the evidence that you are providing to substantiate the above statement
and (if applicable) attach it to this form:
SECTION III: Geography
1. Describe the geographic areas for the county, both inside and outside the
proposed service area, including the major population centers, transportation
arteries, significant topographic features (e.g., lakes, mountain ranges, etc.), and
any other geographic factors that affected your service area designation.
SECTION IV: Provider Network Assessment
1. Provide the number of Medicare eligible beneficiaries for each significant city /
town in the requested partial county service area.
2. Partial County Network Assessment Table
CMS holds partial county applicants to the same network criteria (time and
distance standards) as full-county applicants. Because HPMS cannot measure
contracted providers and facilities against requirements at a level smaller than a
full county, you must submit access data for your network in the partial-county
service area you are requesting.
Several weeks following your initial application submission, CMS will issue its
first review/deficiency notice and, in that notice, will name six cities / towns in
your proposed service area that you will use to complete the Partial County
Network Assessment Table. You should upload the table as part of your response
to that first notice, which may also name deficiencies elsewhere in your MA
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application. Do not upload the Partial County Network Assessment Table in your
initial application submission.
To complete the Partial County Network Assessment Table, you will list the
CMS-selected cities / towns as the column headers and provide the time (minutes)
and distance (miles) from a zip code located centrally within each of those
locations to the closest contracted provider / facility of each type as listed on the
Table.
Where you do not meet the CMS time and distance requirements for a particular
provider / facility shown on the HSD Criteria Reference Tables (available at
http://www.cms.gov/MedicareAdvantageApps/), you must submit a network
justification, including your strategy for ensuring access to the applicable services
and the local patterns of care for that particular service. CMS recommends that
you use the HSD Exception Request Template for your justification and attach the
form(s) to your Partial county Network Assessment Table. This is not an official
Exception; applicants cannot request exceptions in partial county service areas.
However, it serves the same purpose within the Partial County review strategy.
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4.14 Partial County Network Assessment Table
Instructions: List the CMS-selected cities/towns (as identified in CMS’ first deficiency notice) in the column headers and list the times and
distances between a centrally-located zip code in each city/town and the closest provider of each type listed in column B. Where the time or
distance do not meet the requirements listed on the HSD Criteria Reference Table, describe your strategy for ensuring access to the applicable
services and the local patterns of care for that service in your Partial County Justification upload.
City/Town #1
Code
Type
001
General Practice
002
Family Practice
003
Internal Medicine
004
Geriatrics
005
Primary Care - Physician Assistants
006
Primary Care - Nurse Practitioners
007
Allergy and Immunology
008
Cardiology
009
Cardiac Surgery DO NOT USE
010
Chiropractor
011
Dermatology
012
Endocrinology
013
ENT / Otolaryngology
014
Gastroenterology
015
General Surgery
016
Gynecology, OB / GYN
017
Infectious Diseases
018
Nephrology
019
Neurology
020
Neurosurgery
021
Oncology - Medical, Surgical
Time
City/Town #2
Distance Time
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City/Town #3
Distance Time
Final
City/Town #4
Distance Time
City/Town #5
Distance Time
Page 88 of 162
City/Town #6
Distance Time
Distance
City/Town #1
Code
Type
Time
022
Oncology - Radiation / Radiation Oncology
023
024
Ophthalmology
Oral Surgery DO NOT USE
025
Orthopedic Surgery
026
Physiatry, Rehabilitative Medicine
027
Plastic Surgery
028
Podiatry
029
Psychiatry
030
Pulmonology
031
Rheumatology
032
Thoracic Surgery DO NOT USE
033
Urology
034
035
Vascular Surgery
Cardiothoracic Surgery
040
Acute Inpatient Hospitals
041
Cardiac Surgery Program
042
Cardiac Catheterization Services
043
Critical Care Services/Intensive Care Units (ICU)
044
Outpatient Dialysis
045
Surgical Services (Outpatient or ASC)
046
Skilled Nursing Facilities
047
Diagnostic Radiology
048
Mammography
049
Physical Therapy
050
Occupational Therapy
051
Speech Therapy
052
Inpatient Psychiatric Facility Services
City/Town #2
Distance Time
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Distance Time
Final
City/Town #4
Distance Time
City/Town #5
Distance Time
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City/Town #6
Distance Time
Distance
Code
Type
054
Orthotics and Prosthetics
055
Home Health
056
Durable Medical Equipment
057
Outpatient Infusion / Chemotherapy
061
Heart Transplant Program
062
Heart / Lung Transplant Program
064
Kidney Transplant Program
065
Liver Transplant Program
066
Lung Transplant Program
067
Pancreas Transplant Program
City/Town #1
City/Town #2
City/Town #3
City/Town #4
City/Town #5
City/Town #6
Time
Distance Time
Distance Time
Distance Time
Distance Time
Distance Time
Distance
**For the category S03 Sum of Primary Care Providers, list the shortest time/distance among the preceding six provider types (001 through 006).
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5 APPENDIX I: Solicitations for Special Needs Plan (SNP)
Proposals
Solicitations for Special Needs Plan Proposals
Specific Requirements for Dual-Eligible SNPs:
All 2014 Applicants seeking to offer a dual-eligible SNP must have a contract with the
State Medicaid Agency(ies) from each state in which the SNP operates. This requirement
applies to all initial, service area expansion and renewal dual-eligible SNP applicants.
The State Medicaid agency contract must contain at least each of the contractual terms
specified in 42. C.F.R. § 422.107 (c) and listed in the “2014 D-SNP State Medicaid
Agency Contract Matrix Upload Document,” which is a separate document included in
the application packet. This contract must specify a period of performance through at
least January 1, 2014 through December 31, 2014. Additionally, under the contract the
MA organization must retain responsibility for providing, or contracting for benefits to be
provided, for individuals entitled to receive medical assistance under Title XIX. Please
note that State Medicaid agencies are not required to enter into contracts with MA
organizations for dual-eligible SNPs.
Existing Dual Eligible SNPs will need to submit a signed and executed State Medicaid
Agency Contract in HPMS on July 1 without submitting any other portion of the SNP
proposal unless the existing D-SNP is changing its D-SNP subtype or applying for a Service
Area Expansion.
Specific Requirements for Institutional SNPs: All 2014 Applicants seeking to offer a
new or expand the service area of an existing institutional SNP must specify whether the
plan will target only institutionalized individuals, only institutional equivalent individuals
living in the community but requiring an institutional level of care, or both subtypes of
individuals. Institutional SNPs targeting institutional equivalent individuals are required
to use the respective State level of care assessment tool to determine the need for
institutional level of care for prospective enrollees. The eligibility assessment must be
performed by an entity other than the MA organization offering the SNP.
Specific Requirements for Severe or Disabling Chronic Condition SNPs: All 2014
Applicants seeking to offer a new or expand the service area of an existing severe or
disabling chronic condition SNP must exclusively serve an individual confirmed to have
one of the CMS-approved chronic conditions. For the sole purpose of determining
eligibility for a chronic condition SNP, CMS has identified several severe or disabling
chronic conditions that meet the Medicare Improvements for Patients and Providers Act
of 2008 (MIPPA) definition: Has one or more co-morbid and medically complex chronic
conditions that are substantially disabling or life-threatening, has a high risk of
hospitalization or other significant adverse health outcomes, and requires specialized
delivery systems across domains of care. The list of CMS-approved chronic conditions is
found in the C-SNP Proposal section of this application.
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2014 Requirements for ALL (both new and existing) SNPs:
Enrollment Requirements: Both existing and new SNPs can only enroll individuals who
meet the statutory definition of special needs individual for the specific SNP. Applicants
should refer to the definition section below to assure that their proposal will comply with
enrolling only those beneficiaries who meet the statutory definition of special needs
individual for their specific type SNP.
Care Management Requirements: All SNPs are required to implement an evidence-based
model of care having explicit components. These components include: 1) measurable
goals specific to the target special needs individuals; 2) an adequate staff structure having
care management roles; 3) an interdisciplinary care team for each beneficiary; 4) a
provider network having specialized expertise pertinent to the target special needs
individuals; 5) training on the model of care for plan personnel and contractors; 6)
comprehensive health risk assessment for each beneficiary; 7) an individualized plan of
care having goals and measurable outcomes for each beneficiary; 8) a communication
network that facilitates coordination of care; and 9) evaluation of the effectiveness of the
model of care. The MA organization must design its model of care to accommodate the
needs of the most vulnerable members of its target population, i.e., the frail, the disabled,
those near the end-of-life, those having multiple or medically complex chronic
conditions, and those who develop end-stage renal disease after enrollment.
Quality Reporting Requirements: All MA organizations are required to collect, analyze,
report, and act on data through a systematic and continuous quality improvement
program. As an MA plan, each SNP must implement a quality improvement program that
focuses on measuring indices of quality, beneficiary health outcomes, and evaluating the
effectiveness of its model of care in meeting the needs of its targeted special needs
individuals.
For each SNP, MA organizations must coordinate the systematic collection of data using
indicators that are objective, clearly defined, and preferably based on valid and reliable
measures. Indicators should be selected from a variety of quality and outcome
measurement domains such as functional status, care transitioning, disease management,
behavioral health, medication management, personal and environmental safety,
beneficiary involvement and satisfaction, and family and caregiver support. SNPs must
document all aspects of the quality improvement program including data collection and
analysis, actions taken to improve the performance of the model of care, and the
participation of the interdisciplinary team members and network providers in quality
improvement activities. The MA organization should document quality improvement
activities and maintain the information for CMS review upon request and during audits.
MA organizations are required to report HEDIS measures (if enrollment threshold is
met), Structure & Process measures, HOS survey (if enrollment threshold is met),
CAHPS survey (if enrollment threshold is met), Part C Reporting Data, and Medication
Therapy Management measures for each SNP.
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Definitions:
Full Benefit Dual Eligible (FBDE or Medicaid only): An individual who does not meet
the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either
categorically or through optional coverage groups based on Medically Needy status,
special income levels for institutionalized individuals, or home and community-based
waivers. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible,
premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if
applicable. Medicaid payment of the Medicare Part A or Medicare Part B premiums may be a
Medicaid benefit available to FBDE beneficiaries in certain states.
Qualified Medicare Beneficiary without other Medicaid (QMB only): An individual entitled
to Medicare Part A, with an income of 100% Federal poverty level (FPL) or less and
resources that do not exceed twice the limit for Supplementary Social Security Income (SSI)
eligibility, and who is not otherwise eligible for full Medicaid benefits through the State.
Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and
Medicare deductibles and coinsurance for Medicare services provided by Medicare providers
to the extent consistent with the Medicaid State Plan. Medicaid does not pay towards out-ofpocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare
Part D prescription drug coverage, if applicable.
Qualified Medicare Beneficiary Plus (QMB+): An individual entitled to Medicare Part A,
with income of 100% FPL or less and resources that do not exceed twice the limit for SSI
eligibility, and who is eligible for full Medicaid benefits. Medicaid pays their Medicare Part
A premiums, if any, Medicare Part B premiums, Medicare deductibles and coinsurance, and
provides full Medicaid benefits to the extent consistent with the State Plan. These individuals
often qualify for full Medicaid benefits by meeting Medically Needy standards, or by
spending down excess income to the Medically Needy level. Medicaid does not pay towards
the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug
coverage, if applicable.
Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB only): An
individual entitled to Medicare Part A, with an income that exceeds 100% FPL but less than
120% FPL, with resources that do not exceed twice the SSI limit, and who is not otherwise
eligible for Medicaid. These individuals are eligible for Medicaid payment of the Medicare
Part B premium only. They do not qualify for any additional Medicaid benefits. Medicaid
does not pay towards OOP costs for the deductible, premium, coinsurance, or copayments for
Medicare Part D prescription drug coverage, if applicable.
Specified Low-Income Medicare Beneficiary Plus (SLMB+): An individual who meets the
standards for SLMB eligibility, and who also meets the criteria for full State Medicaid
benefits. The individuals are entitled to payment of the Medicare Part B premium, in addition
to full State Medicaid benefits. These individuals often qualify for Medicaid by meeting
Medically Needy standards or by spending down excess income to the Medically Needy
level. Medicaid does not pay towards OOP costs for the deductible, premium, coinsurance, or
copayments for Medicare Part D prescription drug coverage, if applicable.
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Qualified Disabled and Working Individual (QDWI): An individual who has lost Medicare
Part A benefits due to a return to work, but is eligible to enroll in and purchase Medicare Part
A. The individual’s income may not exceed 200% FPL and resources may not exceed twice
the SSI limit. The individual may not be otherwise eligible for Medicaid. These individuals
are eligible for Medicaid payment of the Part A premium only. Medicaid does not pay
towards OOP costs for the deductible, premium, coinsurance, or copayments for Medicare
Part D prescription drug coverage, if applicable.
Qualifying Individual (QI): An individual entitled to Medicare Part A, with an income at
least 120% FPL but less than 135% FPL, and resources that do not exceed twice the SSI
limit, and who is not otherwise eligible for Medicaid benefits. This individual is eligible for
Medicaid payment of the Medicare Part B premium. Medicaid does not pay towards OOP
costs for the deductible, premium, coinsurance, or copayments for Medicare Part D
prescription drug coverage, if applicable.
All Duals: An all-dual D-SNP has a state Medicaid agency contract to enroll beneficiaries
who are MA eligible and who are entitled to medical assistance under a State/Territorial plan
under Title XIX of the Act. An all-dual D-SNP must enroll all categories of dual eligible
individuals (i.e., FBDE, QMB, QMB+, SLMB, SLMB+, QI and QDWI) including those
with comprehensive Medicaid benefits as well as those with more limited cost-sharing such
as QMBs, SLMBs, and QIs.
Full Duals: A full-dual D-SNP has a state Medicaid agency contract to enroll individuals
who are eligible for: (1) Medical assistance for full Medicaid benefits 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 (2) Medical assistance under section
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
individual was eligible for medical assistance in any part of the month. Sections 1902(a),
1902(f), 1902(p), 1905, and 1935(c)(6) of the Act describe categories of individuals who are
entitled to full Medicaid benefits. This includes QMB+ individuals, SLMB+ individuals, and
other FBDEs.
Medicare Zero Cost Share: A Medicare zero-cost-share D-SNP that has a State Medicaid
agency contract to limit enrollment to QMBs only and QMBs with comprehensive Medicaid
benefits (QMB+)—the two categories of dual eligible beneficiaries who are not financially
responsible for cost-sharing for Medicare Parts A or B. Because QMB-only individuals are
not entitled to full Medicaid benefits, there may be Medicaid cost-sharing required.
Fully-Integrated Dual Eligible SNPs: FIDE SNPs are CMS-approved SNPs that meet all of
the following criteria, as also specified in 42 C.F.R. §422.2:
(1) Enroll special needs individuals entitled to medical assistance under a Medicaid State
plan, as defined in section 1859(b)(6)(B)(ii) of the Act and 42 CFR §422.2;
(2) Provide dually eligible beneficiaries access to Medicare and Medicaid benefits under a
single managed care organization (MCO);
(3) Have a capitated contract with a State Medicaid agency that includes coverage of
specified primary, acute, and long-term care benefits and services, consistent with State
policy, under risk-based financing;
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(4) Coordinate the delivery of covered Medicare and Medicaid health and long-term care
services, using aligned care management and specialty care network methods for high-risk
beneficiaries; and
(5) Employ policies and procedures approved by CMS and the State to coordinate or
integrate enrollment, member materials, communications, grievance and appeals, and quality
improvement.
The FIDE SNP definition at 42 C.F.R. §422.2 requires the plan to have a contract with the
state(s) in its service area specifying that the state(s) will pay the FIDE SNP a capitation
payment for primary, acute and long-term care Medicaid benefits and services in exchange
for the FIDE SNP’s provision of these benefits to its enrollees. In determining whether a DSNP meets the FIDE SNP definition, CMS will allow Long Term Care benefit carve-oouts or
exclusions if the plan can demonstrate that it meets the following criteria:
(1)The plan must be at risk for substantially all of the services under the capitated rate; and
(2)The plan must be at risk for nursing facility services for at least six months (or onehundred and eighty days of the year; and
(3)The individual must not be disenrolled from the plan as a result of exhausting the service
covered under the capitated rate; and
(4)the plan must remain responsible for managing all benefits, including any carved-out
service benefits, notwithstanding the method of payment (e.g., fee-for-service, separate
capitated rate) received by the plan.
Additionally, notwithstanding any benefit care-outs permitted under such an arrangement, DSNPs in states that currently require capitation of long term benefits for a longer duration
than this CMS minimum must maintain this level of capitation.
Dual Eligible Subset: MA organizations that offer D-SNPs may exclude specific groups of
dual eligibles based on the MA organization’s coordination efforts with State Medicaid
agencies. CMS reviews and approves requests for coverage of dual eligible subsets on a caseby-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, provided that the enrollment limitations parallel the
structure and care delivery patterns of the State Medicaid program. In HPMS plans have the
option to select between “Dual Eligible Subset” (which is synonomous with Dual Eligible
Subset – Non-Zero Dollar Cost Share) or “Dual Eligible Subset – Zero Dollar Cost Share”.
Institutional SNP: A SNP that enrolls eligible individuals who continuously reside or are
expected to continuously reside for 90 days or longer in a long-term care (LTC) facility.
These LTC facilities may include a skilled nursing facility (SNF); nursing facility (NF);
(SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); and/or an
inpatient psychiatric facility. An institutional SNP to serve Medicare residents of LTC
facilities must have a contractual arrangement with (or own and operate) the specific
LTC facility(ies).
Institutional Equivalent SNP: An institutional SNP that enrolls eligible individuals living
in the community but requiring an institutional level of care based on the State
assessment. The assessment must be performed using the respective State level of care
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assessment tool and be administered by an entity other than the organization offering the
SNP. This type of SNP may restrict enrollment to individuals that reside in a contracted
assisted living facility (ALF), continuing care retirement community (CCRC), or other
type of residential facility, if necessary to ensure uniform delivery of specialized care.
The need for the enrollment limitation to these facilities must be demonstrated by the ISNP, including how community resources will be organized.
SNP Proposal Applications Instructions
Initial (new) SNP
An Applicant, including an existing MA contractor, offering a new SNP must submit
their SNP proposal by completing HPMS SNP Proposal Application template and
submitting all completed upload documents per HPMS User Guide instructions. A SNP
proposal application must be completed for each SNP type to be offered by the MAO.
The service area of the proposed SNP cannot exceed the existing or pending service
area for the MA contract.
All Applicants requesting to offer a dual-eligible SNP must have a State Medicaid
Agency contract or be in negotiation with the State Medicaid Agency toward that goal.
A dual-eligible SNP must have a State Medicaid Agency contract in place prior to the
beginning of the 2014 contract year and the contract must overlap the entire CMS MA
contract year.
In general, CMS recommends and encourages MA Applicants to refer to 42 CFR 422
regulations to clearly understand the nature of the requirement. Nothing in this
solicitation is intended to supersede the regulations at 42 CFR 422. Failure to reference
a regulatory requirement does not affect the applicability of such requirement. Other
associated MA and Part D applications must also be completed and submitted.
Applicants must read HPMS memos and visit the CMS web site periodically to stay
informed about new or revised guidance documents.
SNP Service Area Expansion (SAE)
An MA organization currently offering a SNP that wants to expand the service area of
this SNP must adhere to the same requirements for submission of an initial SNP
proposal application. The service area of the proposed SNP cannot exceed the existing
or pending service area for the MA contract.
Renewal SNPs that are Not Expanding their Service Area:
An MA organization currently offering a SNP that requires re-approval under the
NCQA SNP Approval process should only submit its Model of Care written narrative and
Model of Care Matrix Upload Document and will not be required to submit any other
portion of the MA application or SNP proposal, unless specifically noted (e.g., in the
instructions for submission of contracts with State Medicaid Agencies). Any SNP that
received a two or three year approval will not be required to submit any other portion of the
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MA application or SNP proposal unless specifically noted (e.g., to meet the requirement for
contracting with a State Medicaid Agency). (Note: The Affordable Care Act amended
section 1859(f) of the Social Security Act to require that all SNPs be approved by National
Committee for Quality Assurance (NCQA) starting January 1, 2012, and subsequent years.
42 C.F.R. §§ 422.4(a) (iv), 422.101(f), and 422.152(g) specify that the NCQA approval
process be based on evaluation and approval of the model of care (MOC), as per CMS
guidance. During Contract Year 2012, all SNPs went through this NCQA SNP Approval
process.)
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1.
C-SNP Proposal Application
Attestation
Response
SNP Proposal Applications
1. Applicant is applying to offer a new severe or disabling chronic condition
Yes/No
SNP.
2. How many new severe or disabling chronic condition SNPs?
Insert number.
3. Applicant is applying to expand an existing severe or disabling chronic
condition SNP.
Yes/No
2.
C-SNP Service Area
Attestation
Response
SNP Service Area
1. Provide a separate service area listing (State and County name and code)
for each different type of dual-eligible SNP being offered.
Note: SNP service area must be equal to or less than the approved or
pending MA service.
Service Area Upload
Document
2. Applicant’s service area is equal to or less than the approved or pending
MA service area.
Yes/No
3. Applicant’s service area covers more than one State. If yes, respond to
question #4 in this section. If no, proceed to the next section.
Yes/No
4. Provide the names of the States.
Insert text.
3.
C-SNP Attestations
Attestation
Response
Severe or Disabling Chronic Conditions
1. Applicant will offer a chronic condition SNP (C-SNP) covering one or
more of the following severe or disabling chronic conditions
Yes/No
2. C-SNP covering only chronic alcohol and other drug abuse
Yes/No
3. C-SNP covering only autoimmune disorders
Yes/No
4. C-SNP covering only cancer
Yes/No
5. C-SNP covering only cardiovascular disorders
Yes/No
6. C-SNP covering only chronic heart failure
Yes/No
7. C-SNP covering only dementia
Yes/No
8. C-SNP covering only diabetes mellitus
Yes/No
9. C-SNP covering only end-stage liver disease
Yes/No
10. C-SNP covering only end-stage renal disease requiring dialysis
Yes/No
11. C-SNP covering only severe hematologic disorders
Yes/No
12. C-SNP covering only HIV\AIDS
Yes/No
13. C-SNP covering only chronic lung disorders
Yes/No
14. C-SNP covering only chronic disabling mental health conditions
Yes/No
15. C-SNP covering only neurologic disorders
Yes/No
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16. C-SNP covering only stroke
Yes/No
17. Single C-SNP covering both cardiovascular disorders and chronic heart Yes/No
failure (Note: Enrollees must have at least one of the chronic conditions in
the group)
18. Single C-SNP covering both cardiovascular disorders and diabetes
(Note: Enrollees must have at least one of the chronic conditions in the
group)
Yes/No
19. Single C-SNP covering both chronic heart failure and diabetes (Note:
Enrollees must have at least one of the chronic conditions in the group)
Yes/No
20. Single C-SNP covering three conditions - cardiovascular disorders,
Yes/No
chronic heart failure, and diabetes (Note: Enrollees must have at least one of
the chronic conditions in the group)
21. Single C-SNP covering both cardiovascular disorders and stroke (Note: Yes/No
Enrollees must have at least one of the chronic conditions in the group)
22. Customized grouping of CMS-approved chronic conditions (Note:
Enrollees must have all chronic conditions in the customized group)
4.
Yes/No
D-SNP Proposal Application
Attestation
Response
SNP Proposal Applications
1. Applicant is applying to offer a new dual-eligible SNP.
Yes/No
2. How many new dual-eligible SNPs?
Insert number.
3. Applicant is applying to expand an existing dual-eligible SNP.
Yes/No
5.
D-SNP Service Area
Attestation
Response
SNP Service Area
1. Provide a separate service area listing (State and County name and code)
for each different type of dual-eligible SNP being offered.
D-SNP State Medicaid
Agency Contract
Note: Applicant’s proposed service area must be equal to or less than the Negotiation Status
counties included in the approved or pending State Medicaid Agency(ies)
Document
contract(s).
2. Applicant’s service area is equal to or less than the approved or pending
MA service area.
Yes/No
3. Applicant’s service area is equal to or less than the counties approved in
the State Medicaid Agency(ies) contract.
Yes/No
4. Applicant’s service area covers more than one State. If yes, respond to
question #5 in this section. If no, proceed to the next section.
Yes/No
5. Provide the names of the States.
Insert text.
6.
D-SNP State Medicaid Agency(ies) Contract(s)
Attestation
Response
State Medicaid Agency Contracts
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1. Applicant has a contract with the State Medicaid Agency(ies) that covers
the MA application year. If yes, go to question #2.
If no, go to question #4.
(Note: Applicants for dual-eligible SNPs (initial, existing, and
existing/expanding) must have a signed State Medicaid Agency(ies)
contract by the CMS specified deadline. If an updated contract or
contract amendment will be needed for the application year, applicant
should go to Question #4.)
Yes/No
Yes/No
2.Applicant wishes the contract with the State Medicaid Agency(ies) to be
If yes, Upload the
revieiwed to determine if it qualifies as a fully integrated dual eligible SNP
completed FIDE SNP
(FIDE).
Contract Matrix
Upload executed
contracts and
3. Provide copy of ALL signed State Medicaid Agency(ies) contract(s) and,
corresponding
for EACH contract, a corresponding Contract Matrix that references where
Contract Matrix for
to locate the MIPPA required provisions.
each State Medicaid
Agency contract.
4. Applicant has contacted the State Medicaid Agency(ies), initiated
contract negotiation, and will have a signed State Medicaid Agency(ies)
contract for the MA application year.
Note: Applicants for dual-eligible SNPs (initial, existing, and
existing/expanding) must have a signed State Medicaid Agency(ies)
contract by the CMS specified deadline. CMS will not approve a SNP
applicant that does not have a State Medicaid Agency(ies) contract.
Yes/No
5. Download the “D-SNP State Medicaid Agency Contract Negotiation
Status Document” and provide a narrative description of the status of your
negotiation with the State Medicaid Agency(ies).
Upload the completed
D-SNP State Medicaid
Agency Contract
Negotiation Status
Document.
6. Provide the State Medicaid contract begin date.
For each of multiple
contracts, reject if <
01/01/2011
7. Provide the State Medicaid contract end date.
For each of multiple
contracts, reject if >
12/31/2011
8.Does the applicant want the State Medicaid Agency contract to be
reviewed to determine if it qualifies as a FIDE SNP for the contract
period(s) identified in numbers in 6 and 7.
Yes/No
Attestation
Response
State Medicaid Agency(ies) contract enrolled population
1. Applicant will have an executed State Medicaid Agency(ies) contract to
cover one or more of the enrollment categories listed below. Select all
enrollment categories that apply.
Note: The selected enrollment categories must match those listed in the
executed State Medicaid Agency(ies) contract.
Drop-down Menu
a. Qualified Medicare Beneficiary Plus(QMB+) dual-eligible
b. Specified Low-income Medicare Beneficiary Plus (SLMB+) dual-eligible
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c. Other full benefit dual-eligible also known as "Medicaid only”
d. Qualified Medicare Beneficiary (QMB) dual-eligible
e. Specified Low-income Medicare Beneficiary (SLMB) dual-eligible
f. Qualifying Individual (QI) dual-eligible
g. Qualified Disabled and Working Individual (QDWI) dual-eligible
h. Dual-eligible who are institutionalized
i. Dual-eligible who are institutional equivalent
j. Medicaid Subset enrollment category other than those listed above
2. Provide a description of 1.j., the Medicaid Subset for an enrollment
population other than what is listed above in 1.a.-1.i.
Insert text.
Attestation
Response
State Medicaid Agency(ies) contact
1. Provide the name of the contact individual at the State
Medicaid Agency(ies).
Insert Text
2. Provide the address of the State Medicaid Agency contact
person.
Insert Text
3. Provide the phone number of the State Medicaid Agency
contact person.
Insert number
4. Provide the e-mail address of the State Medicaid Agency
contact person.
Insert text
7.
I-SNP Proposal Application
Attestation
Response
SNP Proposal Applications
1. Applicant is applying to offer a new institutional SNP.
Yes/No
2. How many new institutional SNPs?
Insert number.
3. Applicant is applying to expand an existing institutional SNP.
Yes/No
8.
I-SNP Service Area
Attestation
Response
SNP Service Area
1. Provide a separate service area listing (State and County name and code)
for each different type of dual-eligible SNP being offered.
Note: SNP service area must be equal to or less than the approved or
pending MA service.
Service Area Upload
Document
2. Applicant’s service area is equal to or less than the approved or pending
MA service area.
Yes/No
3. Applicant’s service area covers more than one State. If yes, respond to
question #4 in this section. If no, proceed to the next section.
Yes/No
4. Provide the names of the States.
Insert text.
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9.
I-SNP Attestations
Attestation
Response
SNPs enrolling individuals residing in institutions
1. Applicant will enroll individuals residing in a long term care
facility under contract with or owned by the organization
Yes/No
offering the SNP.
2. Provide a list of contracted long-term care facilities.
Upload I-SNP Upload Document.
3. Provide attestation for Special Needs Plans (SNP) serving
institutionalized beneficiaries.
Upload I-SNP Attestation
Document.
Attestation
Response
SNPs enrolling individuals eligible as institutional equivalent
1. Applicant will enroll individuals who are institutional
equivalents residing in the community.
Yes/No
2. Provide a list of assisted-living facility(ies) (ALF),
continuing care retirement community(ies) (CCRC), or
other type of residential facility(ies). (respond only if
Applicant is contracting with these facilities).
Upload document.
3. Applicant owns or has an executed contract(s) with each
of the ALFs, CCRCs, or other residential facilities on the
Yes/No/NA
list (if applicable)?
4. Applicant uses the respective State level of care (LOC)
assessment tool to determine eligibility for each
institutional equivalent beneficiary.
Yes/No
Note: The Applicant must use the respective State (LOC)
assessment tool to determine eligibility for institutional
equivalent individuals living in the community.
5. Provide a copy of the State LOC assessment tool.
Upload document.
6. Provide the URL for the State LOC assessment tool if
accessible on the State website.
http://xxxxxxxxxxxx.xxx
7. Applicant uses an unrelated third party entity to perform
the LOC assessment.
Yes/No
Note: The Applicant must use an unrelated third party
entity to perform the LOC assessment.
8. Provide the name of the entity(ies) performing the LOC
assessment.
Insert text.
9. Provide the address of the entity(ies) performing the
LOC assessment.
Insert text.
10. Provide the relevant credential (e.g., RN for registered
nurse, LSW for licensed social worker, etc.) of the staff
from the entity(ies) performing the LOC assessment.
Insert text.
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10.
ESRD Waiver Request
Attestation
Response
ESRD Waiver Requests
1. Applicant requests an ESRD waiver. If yes, respond to questions 2
through 10 below. If no, proceed to the next section.
Yes/No
2. Provide a description of how the applicant intends to serve the unique
needs of the ESRD enrollees in the ESRD Waiver Request Upload
Document.
Upload ESRD Upload
Document.
3. Provide a description of any additional service(s) provided to members
with ESRD.
Upload ESRD Upload
Document.
4. Provide a description of the interdisciplinary care team coordinator role Upload ESRD Upload
in the assessment and delivery of services needed by members with ESRD. Document.
5. If the applicant is delegating ESRD care, case management or care
Upload ESRD Upload
coordination, the applicant must completely describe the arrangement.
Document.
6. Provide a list of the contracted nephrologist(s)
Upload ESRD Upload
Document.
7. Provide a list of the contracted dialysis facility(ies).
Upload ESRD Upload
Document.
8.Describe the dialysis options available to beneficiaries (e.g., home
dialysis; nocturnal dialysis).
Upload ESRD Upload
Document.
9. Provide a list of the contracted kidney transplant facility(ies).
Upload ESRD Upload
Document.
10.Describe beneficiary access to contracted kidney transplant facilities,
including the average distance beneficiaries must travel to reach a
contracted kidney transplant facility.
11.
Upload ESRD Upload
Document.
Model of Care Attestations
Attestation
Response
Written Care Management Plan
1. Applicant has a written care management plan that describes its model of
Yes/No
care.
2. Complete and upload the Model of Care Matrix Upload Document.
Upload
3. Upload a copy of the written care management plan.
Upload
Attestation
Response
Model of Care Goals
1. Applicant has the goal to improve access to medical, mental health, and
social services for its enrolled special needs individuals.
Yes/No
2. Applicant has the goal to improve access to care for its enrolled special
needs individuals.
Yes/No
3. Applicant has the goal to improve coordination of care through an
identified point of contact for its enrolled special needs individuals.
Yes/No
4. Applicant has the goal to provide seamless transitions across healthcare
settings, care providers, and health services for its enrolled special needs
individuals.
Yes/No
5. Applicant has the goal to improve access to preventive health services for Yes/No
2014 Part C Application
Final
Page 103 of 162
its enrolled special needs individuals.
6. Applicant has the goal to assure appropriate utilization of services by its
enrolled special needs individuals.
Yes/No
7. Applicant has the goal to assure cost-effective health services delivery for Yes/No
its enrolled special needs individuals.
8. Applicant has the goal to improve beneficiary health outcomes through
reducing hospitalization and nursing facility placement for its enrolled
special needs individuals.
Yes/No
9. Applicant has the goal to improve beneficiary health outcomes through
Yes/No
improved independence and self-management for its enrolled special needs
individuals.
10. Applicant has the goal to improve beneficiary health outcomes through
improved mobility and functional status for its enrolled special needs
individuals.
Yes/No
11. Applicant has the goal to improve beneficiary health outcomes through
improved pain management for its enrolled special needs individuals.
Yes/No
12. Applicant has the goal to improve beneficiary health outcomes through
improved quality of life as perceived by its enrolled special needs
individuals.
Yes/No
13. Applicant has the goal to improve beneficiary health outcomes through
improved satisfaction with health status and healthcare services for its
enrolled special needs individuals.
Yes/No
14. Applicant’s model of care goals are written as measurable outcomes.
Yes/No
15. Applicant’s care management plan specifies how it will determine that
model of care goals are met.
Yes/No
16. Applicant’s care management plan specifies what action it will take if
goals are not met.
Yes/No
Attestation
Response
Staff Structure and Care Management Roles
1. Applicant has appropriate staff (employed or contracted) to perform
Yes/No
administrative functions. Specific functions include:
2. Processes enrollment
Yes/No
3. Verifies eligibility of enrollees
Yes/No
4. Processes claims
Yes/No
5. Processes and facilitates resolution of consumer or provider complaints
Yes/No
6. Communicates telephonically and disseminates written plan information
to beneficiaries, network providers
Yes/No
7. Applicant has appropriate staff (employed or contracted) to collect,
analyze, report, and act on performance and health outcome data. Specific
tasks include:
Yes/No
8. Conducts a quality improvement program
Yes/No
9. Reviews and analyzes utilization data
Yes/No
10. Survey beneficiaries, plan personnel and network providers, oversight
agencies, and the public
Yes/No
11. Applicant has appropriate staff (employed or contracted) to coordinate
care for beneficiaries across care settings and providers. Specific functions
include:
Yes/No
2014 Part C Application
Final
Page 104 of 162
12. Authorizes and/or facilitates access to specialists and therapies
Yes/No
13. Advocates, informs, educates beneficiaries on services and benefits
Yes/No
14. Identifies and facilitates access to community resources and social
services
Yes/No
15. Triages beneficiaries care needs
Yes/No
16. Conducts risk assessment
Yes/No
17. Facilitates the implementation of the individualized care plan for each
beneficiary
Yes/No
18. Schedules or facilitates scheduling appointments and follow-up services Yes/No
19. Facilitates transportation services
Yes/No
20. Requests consultation and diagnostic reports from network specialists
Yes/No
21. Facilitates translation services
Yes/No
22. Applicant has appropriate staff (employed or contracted) to deliver
medical, mental health, and social services to beneficiaries.
Yes/No
23. Applicant has appropriate staff (employed or contracted) to manage
Yes/No
healthcare information related to medical, mental health, and social services
delivered to beneficiaries. Specific functions include:
24. Assures maintenance and sharing of healthcare records in accordance to Yes/No
CMS regulations and policies
25. Assures HIPAA compliance.
Yes/No
26. Applicant has appropriate staff (employed or contracted) to perform
administrative oversight duties. Specific administrative oversight duties
include:
Yes/No
27. Oversees plan operations and develops policies
Yes/No
28. Authorizes and/or facilitates access to specialists and therapies
Yes/No
29. Assures current licensure and competency of providers
Yes/No
30. Monitors contractual services to assure contractor compliance
Yes/No
31. Assures statutory and regulatory compliance
Yes/No
32. Evaluate the effectiveness of the model of care.
Yes/No
33. Applicant has appropriate staff (employed or contracted) to perform
clinical oversight duties. Specific clinical oversight duties include:
Yes/No
34. Conducts and/or observes interdisciplinary team meetings randomly
Yes/No
35. Assures care and pharmacotherapy are delivered as planned by the
interdisciplinary team
Yes/No
36. Coordinates care across settings and providers
Yes/No
37. Assures providers adhere to nationally-recognized clinical practice
guidelines in clinical care
Yes/No
38. Assures clinical services are appropriate and timely
Yes/No
39. Monitors provision of services and benefits to assure follow-up
Yes/No
40. Monitors provision of services to assure care is seamlessly transitioned
across settings and providers
Yes/No
41. Conducts targeted medical chart reviews as needed
Yes/No
42. Conducts medication reviews.
Yes/No
Attestation
Response
Interdisciplinary Care Team
2014 Part C Application
Final
Page 105 of 162
1. Applicant assigns each beneficiary to an interdisciplinary care team
composed of primary, ancillary, and specialty care providers. Members of
the interdisciplinary care team include some or all of the following:
Yes/No
2. Primary care physician
Yes/No
3. Nurse practitioner, physician’s assistant, mid-level provider
Yes/No
4. Social worker, community resources specialist
Yes/No
5. Registered nurse
Yes/No
6. Restorative health specialist (physical, occupational, speech, recreation)
Yes/No
7. Behavioral and/or mental health specialist (psychiatrist, psychologist,
drug or alcohol therapist)
Yes/No
8. Board-certified physician
Yes/No
9. Dietitian, nutritionist
Yes/No
10. Pharmacist, clinical pharmacist
Yes/No
11. Disease management specialist
Yes/No
12. Nurse educator
Yes/No
13. Pastoral specialists
Yes/No
14. Caregiver/family member whenever feasible
Yes/No
15. Preventive health/health promotion specialist
Yes/No
16. Applicant facilitates the participation of the beneficiary on the
Interdisciplinary Care Team whenever feasible.
Yes/No
17. Applicant assures that the interdisciplinary care team works together to
manage beneficiary care by performing care management functions. Care
management functions include:
Yes/No
18. Develop and implement an individualized care plan with the
beneficiary/caregiver
Yes/No
19. Conduct care coordination meetings annually
Yes/No
20. Conduct care coordination meetings on a regular schedule
Yes/No
21. Conduct face-to-face meetings
Yes/No
22. Maintain a web-based meeting interface
Yes/No
23. Maintain web-based electronic health information
Yes/No
24. Conduct case rounds on a regular schedule
Yes/No
25. Maintain a call line or other mechanism for beneficiary inquiries and
input
Yes/No
26. Conduct conference calls among plan, providers, and beneficiaries
Yes/No
27. Develop and disseminate newsletters or bulletins
Yes/No
28. Maintain a mechanism for beneficiary complaints and grievances
Yes/No
29. Use e-mail, fax, and written correspondence to communicate.
Yes/No
Attestation
Response
Provider Network and Use of Clinical Practice Guidelines
1. Applicant has a network of providers and facilities through employed,
contracted, or non contracted arrangements with specialized clinical
expertise pertinent to the targeted special needs population. The provider
network includes:
Yes/No
2. Acute care facility, hospital, medical center
Yes/No
3. Laboratory
Yes/No
2014 Part C Application
Final
Page 106 of 162
4. Long-term care facility, skilled nursing facility
Yes/No
5. Pharmacy
Yes/No
6. Radiography facility
Yes/No
7. Rehabilitative facility
Yes/No
8. Primary care providers
Yes/No
9. Nursing professionals
Yes/No
10. Mid-level practitioners
Yes/No
11. Rehabilitation/restorative therapy specialists
Yes/No
12. Social worker/social services specialists
Yes/No
13. Mental health specialists
Yes/No
14. Medical specialists pertinent to targeted chronic conditions and
identified co-morbid conditions
Yes/No
15. Pharmacists and/or clinical pharmacists
Yes/No
16. Oral health specialists
Yes/No
17. Applicant gives priority to having board-certified specialists in the
provider network.
Yes/No
18. Applicant provides access through contracted or employed relationships Yes/No
to a network of providers and facilities having specialized clinical expertise
pertinent to the targeted special needs population. Specific services include:
19. Assess, diagnose, and treat in collaboration with the interdisciplinary
care team
Yes/No
20. Provide 24-hour access to a clinical consultant
Yes/No
21. Conduct conference calls with the interdisciplinary care team as needed Yes/No
22. Assist with developing and updating individualized care plans
Yes/No
23. Assist with conducting disease management programs
Yes/No
24. Provide wound management services
Yes/No
25. Provide pharmacotherapy consultation and/or medication management
clinics
Yes/No
26. Conduct home visits for clinical assessment or treatment
Yes/No
27. Conduct home safety assessments
Yes/No
28. Provide home health services
Yes/No
29. Provide home-based end-of-life care
Yes/No
30. Conduct risk prevention programs such as fall prevention or wellness
promotion
Yes/No
31. Provide telemonitoring services
Yes/No
32. Provide telemedicine services
Yes/No
33. Provide in-patient acute care services
Yes/No
34. Provide hospital-based or urgent care facility-based emergency services Yes/No
35. Provide long-term facility care.
Yes/No
36. Applicant has a process to assure that its network facilities and providers Yes/No
have current licensure and/or certification to perform services that meet the
specialized needs of special needs individuals.
37. Applicant has a credentialing review every three years to assure that its
network providers are credentialed and competent to perform services that
meet the specialized needs of special needs individuals.
2014 Part C Application
Final
Yes/No
Page 107 of 162
38. Applicant has a process to coordinate the delivery of services through a Yes/No
provider and facility network having clinical expertise pertinent to the
targeted special needs population. The process includes some or all of the
following:
39. Applicant contracts with providers having the clinical expertise to meet Yes/No
the specialized needs of the targeted SNP population
40. Applicant contracts with facilities that provide diagnostic and treatment Yes/No
services to meet the specialized needs of the targeted SNP population
41. Applicant’s contract directs how the network providers and facilities
will deliver services to beneficiaries
Yes/No
42. Applicant has employed or contracted administrative staff that approve
all referrals to network or out-of network providers prior to the delivery of
services and notifies the interdisciplinary care team
Yes/No
43. Applicant has the beneficiary’s interdisciplinary care team approve all Yes/No
referrals to the network or out-of-network providers prior to the delivery of
services and notifies the plan’s administrative staff
44. Applicant has the beneficiary directly contact network or out-of-network Yes/No
providers to schedule necessary services
45. Applicant has a mechanism in place that allows beneficiaries to notify
the plan/and or interdisciplinary team for assistance in obtaining necessary
services.
Yes/No
46. Applicant tracks and analyzes services utilization to assure appropriate
use of services
Yes/No
47. Applicant contacts beneficiaries to remind them about upcoming
appointments
Yes/No
48. Applicant contacts beneficiaries to follow-up on missed appointments.
Yes/No
49. Applicant has a process to coordinate the seamless transition of care
across healthcare settings and providers. The process includes:
Yes/No
50. Applicant has written procedures that direct how the network providers Yes/No
and facilities will deliver services to beneficiaries including transition of
care from setting-to-setting, provider-to-provider, and provider-to-facility
51. Applicant monitors the transition of care from setting-to-setting,
provider-to-provider, provider-to-facility, and notification to the
interdisciplinary care team
Yes/No
52. Applicant has written procedures that require notification to the
Yes/No
interdisciplinary care team and respective providers when transitions of care
occur
53. Applicant tracks and analyzes transitions of care to assure timeliness
and appropriateness of services
Yes/No
54. Applicant disseminates the results of the transition of care analysis to
the interdisciplinary care team
Yes/No
55. Applicant contacts beneficiaries to monitor their status after a transition Yes/No
of care from provider-to-provider, facility-to-facility, or provider-to-facility.
56. Applicant has a process to monitor its providers and assure they deliver Yes/No
evidence-based services in accordance with nationally recognized clinical
protocols and guidelines when available (see the Agency for Healthcare
Research and Quality’s National Guideline Clearinghouse,
http://www.guideline.gov/). The process includes some or all of the
following:
2014 Part C Application
Final
Page 108 of 162
57. Applicant has written procedures to assure that employed or contracted Yes/No
providers deliver services in accordance with nationally recognized clinical
protocols and guidelines when available
58. Applicant’s contract with providers stipulates that contracted providers Yes/No
deliver services in accordance with nationally recognized clinical protocols
and guidelines when available
59. 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.
Yes/No
Attestation
Response
Model of Care Training for Personnel and Providers
1. Applicant trains employed and contracted personnel on the model of care Yes/No
to coordinate and/or deliver all services. Applicant conducts training using
one or more of the following methods:
2. Face-to-face training
Yes/No
3. Web-based interactive training
Yes/No
4. Self-study program (electronic media, print materials)
Yes/No
5. Applicant maintains documentation that model of care training was
completed by employed and contracted personnel.
Yes/No
6. Applicant designated personnel responsible to oversee training
implementation and maintain training records for review upon CMS
request.
Yes/No
7. Applicant has a process for taking action when the required model of care Yes/No
training has not been completed by employed or contracted personnel.
Attestation
Response
Health Risk Assessment
1. Applicant conducts a comprehensive initial health risk assessment of the
medical, functional, cognitive, and psychosocial status as well as annual
health risk reassessments for each beneficiary. The process for health risk
assessment includes some or all of the following:
Yes/No
2. Initial comprehensive health risk assessment is conducted within 90 days Yes/No
of enrollment and results are used to develop the individualized care plan
3. Annual comprehensive health risk assessment is conducted and results
are used to update the individualized care plan
Yes/No
4. Comprehensive initial and annual health risk assessment examines
medical, psychosocial, cognitive, and functional status
Yes/No
5. Comprehensive health risk assessment is conducted face-to-face by the
Applicant
Yes/No
6. Comprehensive health risk assessment is conducted telephonically by the Yes/No
Applicant
7. Comprehensive health risk assessment is conducted by the beneficiary
completing an electronic or paper-based questionnaire.
Yes/No
8. Applicant develops or selects and utilizes a comprehensive risk
assessment tool that will be reviewed during oversight activities. The tool
consists of:
Yes/No
9. An existing validated health risk assessment tool
Yes/No
10.A plan-developed health risk assessment tool
Yes/No
2014 Part C Application
Final
Page 109 of 162
11. An electronic health risk assessment tool
Yes/No
12.A paper health risk assessment tool
Yes/No
13. Applicant standardized the use of the health risk assessment tool for all
beneficiaries
Yes/No
14. Applicant periodically reviews the effectiveness of the health risk
assessment tool
Yes/No
15. Provide a copy of the comprehensive health risk assessment tool.
Yes/No
16. Applicant has a process to analyze identified health risks and stratify
Yes/No
them to develop an individualized care plan that mitigates health risks. The
process includes some or all of the following:
17. Comprehensive health risk analysis is conducted by a credentialed
healthcare professional
Yes/No
18. Applicant notifies the Interdisciplinary Care Team, respective providers, Yes/No
and beneficiary about the results of the health risk analysis
19. Applicant uses predictive modeling software to stratify beneficiary
health risks for the development of an individualized care plan
Yes/No
20. Applicant manually analyzes health risk data to stratify beneficiary
health risks for the development of an individualized care plan
Yes/No
21. Applicant tracks and trends population health risk data to inform the
development of specialized benefits and services.
Yes/No
Attestation
Response
Individualized Care Plan
1. Applicant has written procedures that direct how the interdisciplinary
Yes/No
care team develops and implements a comprehensive individualized plan of
care for each beneficiary. The system includes some or all of the following:
2. Each beneficiary is assigned an interdisciplinary care team that develops Yes/No
the individualized care plan with beneficiary involvement when feasible
3. Results from the initial health risk assessment are used to develop the
individualized care plan
Yes/No
4. Beneficiary’s medical history is used to develop the individualized care
plan
Yes/No
5. Beneficiary’s healthcare preferences are incorporated in the
individualized care plan
Yes/No
6. Interdisciplinary care team members update the individualized care plan
as beneficiary health status changes
Yes/No
7. Interdisciplinary care team notifies respective providers and beneficiaries Yes/No
when they update care plans that result from health status changes.
8. Applicant has a written process to facilitate beneficiary/caregiver
participation in care planning when feasible. The process includes some or
all of the following:
Yes/No
9. Beneficiaries and/or caregivers participate face-to-face in care planning
Yes/No
10. Beneficiaries and/or caregivers participate telephonically in care
planning
Yes/No
11. Beneficiaries and/or caregivers participate in care planning through an
exchange of written correspondence with their interdisciplinary team
Yes/No
12. Beneficiaries and/or caregivers participate in care planning through a
web-based electronic interface or virtual correspondence
Yes/No
2014 Part C Application
Final
Page 110 of 162
13. Applicant has a written procedure for maintaining the documented care Yes/No
plan for each beneficiary that complies with HIPAA.
14. Applicant facilitates access to the documented care plan for the
Interdisciplinary Care Team, respective providers, and beneficiaries.
Yes/No
Attestation
Response
Health Risk Assessment to Communication Systems
1. Applicant has written procedures to coordinate the delivery of services
and benefits through communication systems connecting plan personnel,
providers, and beneficiaries. These systems include some or all of the
following:
Yes/No
2. Call-line for beneficiary inquiries
Yes/No
3. Call-line for provider network inquiries
Yes/No
4. Care coordination meetings
Yes/No
5. Case rounds
Yes/No
6. Complaints and grievances documentation and system for resolution
Yes/No
7. Committees (standing and ad hoc)
Yes/No
8. Conference calls
Yes/No
9. E-mails, faxes, written correspondence
Yes/No
10. Electronic network for meetings, training, information, communication
Yes/No
11. Electronic records (administrative data and/or clinical care)
Yes/No
12. Newsletter, bulletin
Yes/No
13. Person-to-person direct interface.
Yes/No
14. Applicant has written procedures to coordinate communication among
the interdisciplinary care team members and the beneficiary. The system
includes some or all of the following:
Yes/No
15. Regularly scheduled face-to-face team meetings
Yes/No
16. Regularly scheduled team conference calls
Yes/No
17. Regularly scheduled web-based team networking
Yes/No
18. Team access to shared electronic health information
Yes/No
19. Randomly scheduled team meetings conducted when needed.
Yes/No
20. Applicant has written procedures describing how communication among Yes/No
stakeholders is documented and maintained as part of the administrative and
clinical care records. Documentation includes some or all of the following:
21. Written minutes
Yes/No
22. Recordings
Yes/No
23. Transcripts from recordings
Yes/No
24. Newsletters, bulletins
Yes/No
25. Web-based database
Yes/No
26. Applicant’s written plan identifies the personnel having oversight
responsibility for its communication network.
Yes/No
Attestation
Response
Care Management for the Most Vulnerable Subpopulations
1. Applicant has written procedures to identify the most vulnerable
beneficiaries enrolled in the SNP.
Yes/No
2. Applicant delineated care management services it will provide for its
Yes/No
2014 Part C Application
Final
Page 111 of 162
most vulnerable beneficiaries. These add-on services address the specialized
needs of the following vulnerable special needs individuals within each
target population:
3. Frail
Yes/No
4. Disabled
Yes/No
5. Beneficiaries developing end-stage renal disease after enrollment
Yes/No
6. Beneficiaries near the end-of-life
Yes/No
7. Beneficiaries having multiple and complex chronic conditions.
Yes/No
Attestation
Response
Performance and Health Outcome Measurement
1. Applicant collects, analyzes, reports, and acts on data to annually
evaluate the effectiveness of its model of care. This evaluation process
includes examining the effectiveness of some or all of the following model
of care elements by demonstrating:
Yes/No
2. Improved access to medical, mental health, and social services
Yes/No
3. Improved access to affordable care
Yes/No
4. Improved coordination of care through a single point of care management Yes/No
5. Improved transition of care across settings and providers
Yes/No
6. Improved access to preventive health services
Yes/No
7. Improved beneficiary health outcomes
Yes/No
8. Quality and/or improved service delivery and oversight of services
through appropriate staffing and implementation of roles
Yes/No
9. Quality and/or improved coordination of care through implementation of Yes/No
the interdisciplinary care team
10. Quality and/or improved service delivery through a competent provider Yes/No
network having specialized expertise and implementing evidence-based
practice guidelines
11. Quality and/or improved coordination of care through identification and Yes/No
stratification of health risks
12. Quality and/or improved coordination of care through implementation
of a dynamic individualized care plan addressing identified health risks
Yes/No
13. Quality and/or improved coordination of care through effective
communication networks and documentation of care
Yes/No
14. Quality and/or improved coordination of care for vulnerable
beneficiaries through implementation of the model of care.
Yes/No
15. Applicant has written procedures to collect, analyze, report, and act on
data using a variety of strategies. Strategies include some or all of the
following:
Yes/No
16. Internal quality assurance specialists implementing and evaluating a
performance improvement program
Yes/No
17. External quality assurance consultants implementing and evaluating a
performance improvement program
Yes/No
18. Participation by plan, provider network, and beneficiaries/caregivers
Yes/No
19. Data collection and analysis via electronic software
Yes/No
20. Data collection and analysis via manual techniques.
Yes/No
2014 Part C Application
Final
Page 112 of 162
21. Applicant takes actions to improve the model of care. Actions include
some or all of the following:
Yes/No
22. Changes in policies or procedures
Yes/No
23. Changes in staffing patterns or personnel
Yes/No
24. Changes in provider or facility network
Yes/No
25. Changes in systems of operation
Yes/No
26. Communication of results internally and externally.
Yes/No
27. Applicant documents its evaluation of the effectiveness of its model of
care and assures access to the documentation for all stakeholders.
Yes/No
28. Applicant designates personnel having oversight responsibility for the
evaluation of the model of care effectiveness.
Yes/No
29. Applicant communicates the results of its model of care evaluation to all Yes/No
stakeholders as identified by the CMS and SNP.
12.
Quality Improvement Program Requirements
Attestation
Response
SNP Quality Improvement Program Requirements
1. Applicant has a written plan including policies, procedures, and a systematic
methodology to conduct an overall quality improvement program that is specific Yes/No
to its targeted special needs individuals.
2. Applicant has a health information system to collect, analyze, and integrate
valid and reliable data to conduct its overall quality improvement program.
Yes/No
3. Applicant has a system to maintain health information for CMS review as
requested.
Yes/No
4. Applicant has a system to ensure that data collected, analyzed, and reported
are accurate and complete.
Yes/No
5. Applicant conducts an annual review of the effectiveness of its quality
improvement program.
Yes/No
6. Applicant takes action to correct problems identified through its quality
improvement activities as well as complaints from beneficiaries and providers.
Yes/No
7. Applicant conducts one or more chronic care improvement programs to
improve health outcomes for beneficiaries having chronic conditions.
Yes/No
8. Applicant identifies beneficiaries with multiple or severe chronic conditions
that would benefit from participation in a chronic care improvement program.
Yes/No
9. Applicant has a mechanism to monitor beneficiaries that participate in a
chronic care improvement program.
Yes/No
10. Applicant conducts one or more quality improvement projects on clinical or
Yes/No
non-clinical areas.
11. For each quality improvement project, Applicant measures performance,
applies interventions to improve performance, evaluates performance, and
conducts periodic follow-up to ensure the effectiveness of the intervention.
Yes/No
12. For each quality improvement project, Applicant evaluates performance
using quality indicators that are objective, clearly defined, and correspond to
measurable outcomes such as changes in health status, functional status, and
beneficiary satisfaction.
Yes/No
13. For each quality improvement project, Applicant collects, analyzes, reports, Yes/No
2014 Part C Application
Final
Page 113 of 162
and acts on valid and reliable data, and achieves demonstrable improvement
from interventions.
14. For each special needs plan, Applicant collects, analyzes, and reports data
that measure health outcomes and indices of quality pertaining to the
Yes/No
management of care for its targeted special needs population (i.e., dual-eligible,
institutionalized, or chronic condition) at the plan level.
15. For each special needs plan, Applicant collects, analyzes, and reports data
that measure access to care (e.g., service and benefit utilization rates, or
timeliness of referrals or treatment).
Yes/No
16. For each special needs plan, Applicant collects, analyzes, and reports data
that measure improvement in beneficiary health status (e.g., quality of life
indicators, depression scales, or chronic disease outcomes).
Yes/No
17. For each special needs plan, Applicant collects, analyzes, and reports data
that measure staff implementation of the SNP model of care (e.g., National
Committee for Quality Assurance accreditation measures or medication
reconciliation associated with care setting transitions indicators).
Yes/No
18. For each special needs plan, Applicant collects, analyzes, and reports data
that measure comprehensive health risk assessment (e.g., accuracy of acuity
stratification, safety indicators, or timeliness of initial assessments or annual
reassessments).
Yes/No
19. For each special needs plan, Applicant collects, analyzes, and reports data
that measure implementation of an individualized plan of care (e.g., rate of
participation by IDT members and beneficiaries in care planning).
Yes/No
20. For each special needs plan, Applicant collects, analyzes, and reports data
that measure use and adequacy of a provider network having targeted clinical
expertise (e.g., service claims, pharmacy claims, diagnostic reports, etc.)
Yes/No
21. For each special needs plan, Applicant collects, analyzes, and reports data
that measure delivery of add-on services and benefits that meet the specialized
needs of the most vulnerable beneficiaries (frail, disabled, near the end-of-life,
etc.).
Yes/No
22. For each special needs plan, Applicant collects, analyzes, and reports data
that measure provider use of evidence-based practices and/or nationally
recognized clinical protocols.
Yes/No
23. For each special needs plan, Applicant collects, analyzes, and reports data
that measure the effectiveness of communication (e.g., call center utilization
rates, rates of beneficiary involvement in care plan development, analysis of
beneficiary or provider complaints, etc.).
Yes/No
24. For each special needs plan, Applicant collects, analyzes, and reports data
that measure CMS-required data on quality and outcomes measures that will
enable beneficiaries to compare health coverage options. These data include
HEDIS, HOS, and/or CAHPS data.
Yes/No
25. For each special needs plan, Applicant collects, analyzes, and reports data
that measure CMS-required Part C Reporting Data Elements that will enable
CMS to monitor plan performance.
Yes/No
26. For each special needs plan, Applicant collects, analyzes, and reports CMS- Yes/No
required Medication Therapy Management measures that will enable CMS to
monitor plan performance.
27. For each special needs plan, Applicants agrees to disseminate the
results of the transitions of care analysis to the interdisciplinary care
team.
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Yes/No
Page 114 of 162
28. Provide a copy of the MAO’s written plan that describes its overall quality
improvement program.
Upload
29. Provide a completed copy of the Quality Improvement Program Matrix
Upload Document.
Upload Quality
Improvement
Program Matrix
Upload Document.
13.
C-SNP Upload Document
Please complete and upload this document into HPMS per HPMS MA Application User Guide
instructions.
2014 Severe or Disabling Chronic Condition SNP Upload Document
Applicant's Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter CMS contract number here.
Provide the service area (County, State name and code) for the severe or disabling chronic condition
SNP being offered.
County Name
State Name
State & County Code
Enter County name here.
Enter State 2 letter abbreviation here. Enter State & County Code here.
14.
D-SNP Upload Document
Applications for a new dual-eligible SNP or a Service Area Expansion to an existing dual-eligible SNP as
well as all existing D-SNPs must have a signed State Medicaid Agency(ies) contract by July 1, 2012. If an
existing D-SNP, new or SAE applicant DOES NOT have an executed State Medicaid Agency contract,
please complete and upload this document into HPMS per the HPMS MA Application User Guide
instructions.
2014 D-SNP State Medicaid Agency Contract Negotiation Status
Document
Applicant's Contract Name (as provided in HPMS):
Enter contract name here.
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CMS Contract Number:
Enter CMS contract number here.
1. New and SAE applicants as well as existing D-SNPs must contact the State Medicaid Agency and
initiate State Medicaid Agency contract negotiations. Enter the information for the State Medicaid
Agency contact individual below.
Enter your response to #1 here.
2. Applicant’s proposed SNP service area(s) must be consistent with the State Medicaid Agency contract
approved service area(s):
a) Equal to or less than the approved or pending Medicare Advantage organization (MAO) service
area
b) Equal to or less than the counties approved by the State Medicaid Agency
Enter your response to # 2 here.
3. List the service area approved by the State Medicaid Agency(ies).
NOTE: The service area specified in the State Medicaid contract cannot exceed the same
service area approved or pending for the Medicare Advantage organization applicant.
County Name
State Name
State & County Code
Enter Parish name here.
Enter State 2 letter abbreviation
Enter State & County Code here.
here.
4. Provide a description of your progress toward negotiating the MA organization’s responsibilities,
including financial obligations, to provide or arrange for Medicaid benefits covered in the State
Medicaid contract.
Note: The contract must specify the following items:
• Describe the process by which the D-SNP provides or arranges for Medicaid benefits, including
any financial obligations in the contract between the State Medicaid agency and the entity.
•
Specify how the Medicare and Medicaid benefits are integrated and/or coordinated.
Enter your response to #4 here.
5. Provide a full description of your progress toward negotiating the category(ies) of eligibility for
dual-eligible beneficiaries enrolled under the SNP as describe in the Statute at sections 1902(a),
1902(f), 1902(p), and 1905.
All Duals: QMB, QMB+,SLMB, SLMB+,QI,QDWI, FDBE *
Full Benefit Dual Eligible: QMB+, SLMB+, and FBDE*
Medicare Zero-Dollar Cost Share: QMB, QMB+
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Dual Eligible Subset D-SNPs: Targeted populations that align with those that are defined under the State
Medicaid Plan or are approved on a case by case basis by CMS.** ***
* As defined under the State Medicaid plan
** All Medicaid subsets must be defined in the State Medicaid Agency Contract
*** Medicaid subset targeted populations may include: a) Qualified Medicare Beneficiary Plus(QMB+)
dual-eligible individual; b) Specified Low-income Medicare Beneficiary Plus (SLMB+) dual-eligible
individual; c) other full benefit dual-eligible individual also known as "Medicaid only”; d) Qualified
Medicare Beneficiary (QMB) dual-eligible individual; e) Specified Low-income Medicare Beneficiary
(SLMB) dual-eligible individual; f) Qualifying Individual (QI) dual-eligible individual; g) Qualified Disabled
and Working Individual (QDWI) dual-eligible individual; h) dual-eligible individual who is institutionalized;
i) dual-eligible individual who is an institutional equivalent residing in the community; and j) any Medicaid
subset enrollment category other than those previously listed (applicant must specify any other Staterequired enrollment category).
Enter your response to #5 here.
6. Provide a full description of your progress toward negotiating the Medicaid benefits covered in the
State Medicaid contract.
Provide information on the benefit design and administration, as well as assigning plan responsibility to
provide or arrange for the Medicaid benefit.
NOTE: These are the Medicaid services that the organization is obligated to provide or arrange under
its State contract, not Medicare Part C or Medicare supplemental benefits that are listed at the time of
your Medicare Advantage BID
Enter your response to #6 here.
7. Provide a full description of your progress toward negotiating the cost-sharing protections covered
in the State Medicaid contract.
Please demonstrate how the D-SNP would enforce limits on the OOP costs for dual-eligibles. Meeting this
contracting element requires that D-SNPs not impose cost-sharing requirements on specified dual-eligible
individuals (i.e., FIDE individuals, QMBs, or any other population designated by the State) that would exceed
the amounts permitted under the State Medicaid plan if the individual were not enrolled in the D-SNP.
NOTE: Specifically indicate that the Medicaid entity will not bill or hold the member responsible in any
way for charges or deductibles for Medically Necessary Covered Services.
Enter your response to #7 here.
8. Provide a full description of your progress toward negotiating the identification and sharing of
written information on Medicaid provider participation covered in the State Medicaid contract.
NOTE: The description must contain language indicating the process for the State to identify and
share information on providers contracted with the State Medicaid agency for inclusion in the SNP
provider directory. Although CMS does not require all providers to accept both Medicare and
Medicaid, the D-SNP’s Medicare and Medicaid networks should meet the needs of the dual-eligible
population served and be adequate enough to serve the targeted population volume as specified.
Enter your response to #8 here.
9. Provide a full description of your progress toward negotiating the process to verify Medicaid
eligibility of individuals through the State.
NOTE: The description must contain language on how the State Medicaid Agency will provide MA
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organizations with access to real time information verifying eligibility of enrolled dual-eligible
members. The agreed upon eligible verification process must be described in detail. The targeted
group(s) must be specified in the State Medicaid Agency contract.
Enter your response to #9 here.
10. Provide a full description of your progress toward negotiating the process to coordinate Medicare
and Medicaid services for dual-eligible enrollees.
Enter your response to #10 here.
15.
D-SNP State Medicaid Agency Contract Matrix
Please complete and upload this document into HPMS per HPMS MA Application User Guide
Instructions for completed (i.e., signed) contracts with the State Medicaid Agency. This applies to
previously signed contracts that are still effective due to it being a multi-year contract or an evergreen
contract.
STATE CONTRACT/SUB CONTRACT REQUIREMENTS
CMS Regulations – 42 CFR 422.107 (c)
Page
Number(s)
Section
Number
Comments
Reviewer Findings
(For CMS Reviewer
Use Only)
MA organizations responsibility, including
financial obligations, to provide or arrange for
Medicaid benefits
The contract must specify the following items:
•
•
•
•
Terms and conditions;
Duties of the Medicaid contract or
arrangement;
Third party liability and coordination of
benefits;
Compliance with Federal, State and Local
Law
Category(ies) of eligibility for dual-eligible
beneficiaries enrolled under the SNP, as
described under the Statute at sections 1902(a),
1902(f), 1902(p), and 1905.
•
Any enrollment limitations for Medicare
beneficiaries under this SNP must
parallel any enrollment limitations under
the Medicaid program
Note: If applicable, please use State aid codes to
identify category of duals being enrolled.
Additional guidance can be found at the following
link:
http://www.cms.hhs.gov/DualEligible/02_DualEli
gibleCategories.asp#TopOfPage
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.
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Please complete and upload this document into HPMS per HPMS MA Application User Guide
Instructions for completed (i.e., signed) contracts with the State Medicaid Agency. This applies to
previously signed contracts that are still effective due to it being a multi-year contract or an evergreen
contract.
STATE CONTRACT/SUB CONTRACT REQUIREMENTS
CMS Regulations – 42 CFR 422.107 (c)
Page
Number(s)
Section
Number
Comments
Reviewer Findings
(For CMS Reviewer
Use Only)
Cost-sharing protections covered under the
SNP
Specifically indicate that MA organizations
offering D-SNPs must enforce limits on the
Out Of Pocket costs for dual-eligibles. DSNPs must not impose cost-sharing
requirements on specified dual-eligible
individuals that would exceed the amounts
permitted under the State Medicaid plan if the
individual were not enrolled in the D-SNP..
Note: Covered services under Medicaid may also,
depending on State law and policy, include a
provider network and prior authorization
component, except for emergency services.
Identification and sharing of information on
Medicare provider participation
Must contain language indicating that the MA SNP
has written procedures for ensuring Medicaid
network adequacy, including access standards.
Verification of enrollee’s eligibility for both
Medicare and Medicaid
The targeted group(s) must be specified in the
State Medicaid agency contract.
Service area covered by the SNP
The service area specified in the State Medicaid
contract must at a minimum, cover the same
service area as the MA SNP.
The contract period for the SNP
The contracting period between the State Medicaid
agency and the DE SNP must specify that it will
continue through the contract year. (January 1December 31 of the year following the due date) If
not, the plan may indicate the evergreen clause
within the contract and provide an explanation of
when the State issues updated rates.
16. Fully Integrated Dual Eligible (FIDE) Special Needs Plan (SNP) Contract
Review Matrix
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Plans should use this document to identify where each FIDE SNP element is met within their contract(s). The
matrix will be used to assist the Centers for Medicare and Medicaid Services (CMS) in conducting the FIDE
SNP determination reviews.
FULLY INTEGRATED DUAL ELIGIBLE (FIDE) SPECIAL NEEDS PLAN (SNP)
CONTRACT REVIEW MATRIX
Plan Name: _____________________________
Meeting the definition of a FIDE SNP
– CMS 4144-F
Date: __________________
Page
Section
Number(s) Number
Comments
(1) Enroll special needs individuals
entitled to medical assistance under a
Medicaid State plan, as defined in section
1859(b)(6)(B)(ii) of the Act and § 422.2.
The contract between the MAO and the state
specifies that the MCO can only enroll dual
eligibles.
(2) Provide dual eligible beneficiaries
access to Medicare and Medicaid benefits
under a single managed care organization
(MCO).
There is a contract in place between the
MAO and the state and CMS to offer a DSNP.
(3) Have a capitated contract with a State
Medicaid agency that includes coverage of
specified primary, acute and long-term
care benefits and services, consistent with
State policy.
The contract includes for provision of a
capitated payment for covered services.
Coverage of primary, acute and long-term
care benefits are offered and covered by a
capitated arrangement.
(4) Coordinate the delivery of covered
Medicare and Medicaid health and long
term care services, using aligned care
management and specialty care network
methods for high-risk beneficiaries.
The MAO benefit package includes services
such as assessments, care coordination, and
case management to improve outcomes for a
high-needs population.
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Plans should use this document to identify where each FIDE SNP element is met within their contract(s). The
matrix will be used to assist the Centers for Medicare and Medicaid Services (CMS) in conducting the FIDE
SNP determination reviews.
FULLY INTEGRATED DUAL ELIGIBLE (FIDE) SPECIAL NEEDS PLAN (SNP)
CONTRACT REVIEW MATRIX
Plan Name: _____________________________
Meeting the definition of a FIDE SNP
– CMS 4144-F
Date: __________________
Page
Section
Number(s) Number
Comments
(5) Employ policies and procedures
approved by CMS and the State to
coordinate or integrate member materials,
including enrollment, communications,
grievance and appeals, and quality
assurance.
The contract requires that the MCO
integrate member materials and
administrative processes and meet
applicable state requirements. The contract
indicates that prior approval by the state and
CMS is required for marketing and
enrollment materials.
17.
I-SNP Upload Document
Please complete and upload this document into HPMS per HPMS MA Application User Guide instructions.
Applicant's Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter CMS contract number here.
Specific I-SNP Population: Place an “X” to the left. (Mark only one.)
A. Applicant will enroll ONLY individuals living in an institution.
B. Applicant will enroll ONLY individuals who are institutional equivalent and living in the community.
C. Applicant will enroll BOTH institutionalized and institutional equivalent individuals.
Applicant Enrolling ONLY Institutionalized
1. Provide the service area (County, State name and code) for the institutional SNP being offered.
County Name
State Name
State & County Code
Enter County name here.
Enter State 2 letter abbreviation here.
Enter State & County Code here.
2. Provide a list of contracted long-term care facilities. (If Applicant is contracting with LTC facilities).
Name of Contracted Long-term
Medicaid Provider # (If applicable).
Facilities Address
Care Facilities
Enter name of long-term care
facilities here.
Enter Medicaid provider # here.
Enter facilities address here.
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Name of Contracted Long-term
Care Facilities
Medicare Provider # (If applicable).
Facilities Address
Applicant Enrolling ONLY Institutional Equivalent Individuals
1. Provide the service area (County, State name and code) for the institutional SNP being offered.
County Name
State Name
State & County Code
Enter County name here.
Enter State 2 letter abbreviation here.
Enter State & County Code here.
2. Provide the name of the entity(ies) performing the level of care (LOC) assessment for enrolling individuals
living in the community.
Enter name of the entity(ies) performing the LOC assessment here.
3. Provide the address of the entity (ies) performing the LOC assessment.
Enter the address of the entity(ies) performing the LOC assessment here.
4. Provide the relevant credential (e.g., RN for registered nurse, LSW for licensed social worker, etc.) of the
staff from the entity(ies) performing the LOC assessment.
Enter the relevant credential from the staff of the entity(ies) performing the LOC assessment here.
5. Provide a list of assisted-living facilities (if Applicant is contracting with ALFs)
Name of Assisted-living Facilities
Medicaid Provider #
Facilities Address
Enter Name of assisted-living
facilities here.
Enter Medicaid provider # here.
Enter facilities address here.
Applicant Enrolling BOTH Institutionalized and Institutional Equivalent
1. Provide the service area (County, State name and code) for the institutional SNP being offered.
County Name
State Name
State & County Code
Enter County name here.
Enter State 2 letter abbreviation here.
Enter State & County Code here.
2. Provide a list of contracted long-term care facilities.
Name of Contracted Long-term
Medicare Provider #
Care Facilities
Enter name of long-term care
facilities here.
Enter Medicaid provider # here.
Facilities Address
Enter facilities address here.
3. Provide the name of the entity(ies) performing the level of care (LOC) assessment for enrolling individuals
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living in the community.
Enter name of the entity(ies) performing the LOC assessment here.
4. Provide the address of the entity(ies) performing the LOC assessment.
Enter the address of the entity(ies) performing the LOC assessment here.
5. Provide the relevant credential (e.g., RN for registered nurse, LSW for licensed social worker, etc.) of the
staff from the entity(ies) performing the LOC assessment.
Enter the relevant credential from the staff of the entity(ies) performing the LOC assessment here.
6. Provide a list of assisted-living facilities (if Applicant is contracting with ALFs)
Name of Assisted-living Facilities
Medicaid Provider #
Facilities Address
Enter Name of assisted-living
facilities here.
Enter Medicaid provider # here.
Enter facilities address here.
18.
I-SNP Attestation Upload Document
Please complete and upload this document into HPMS per HPMS MA Application User Guide instructions.
2014 Institutional SNP Attestation Upload Document
Applicant's Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter contract number here.
Provide attestation for Special Needs Plans (SNP) Serving institutionalized beneficiaries.
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
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 further attest that the contract
with all LTCs stipulates that the MAO has the authority to conduct on-site visits to observe care, review credentialing
and competency assessment records, review beneficiary medical records, and meet with LTC personnel to assure
quality and safe care of its beneficiaries.
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 assure that the necessary arrangements with community resources 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 beneficiary according to CMS
enrollment/disenrollment policies and procedures. Appropriate documentation includes the executed MAO 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 ____________________________
CEO_________________________________________ Date ____________________________
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19.
ESRD Waiver Request Upload Document
Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.
CY 2014 ESRD Upload Document
Applicant's Contract Name (as provided in HPMS):
Enter contract name here.
Applicant’s CMS Contract Number:
Enter contract number here.
1. Provide a description of how Applicant intends to monitor and serve the unique needs of the ESRD enrollees
including care coordination. Describe how/why the services you provide are relevant to ESRD enrollees.
Include a clinical and social profile of ESRD beneficiaries, their most frequent co-morbidities, problems
with Activities of Daily Living (ADLs), living arrangements, etc.
Enter your response to #1 here.
2.Provide a listing of any additional service(s) provided to members with ESRD. Include a description of
how/why these services are relevant to ESRD enrollees. Only list benefits that are already required for a
Medicare Advantage plan to the extent that the applicant offers enhancements to these benefit(s) that
specifically address the needs of the ESRD membership. As examples, additional benefits to be described
may include but are not limited to:
•
•
•
Transportation
Support groups (e.g., beneficiary; family; caregiver)
Self-care education (e.g., nutrition; wound care)
Enter your response to #2 here.
3. Provide a description of the interdisciplinary care team’s coordination role in the assessment and delivery of
services needed by members with ESRD. Include specific details about the interaction of the different
interdisciplinary care team members during both assessment and delivery of services, and address how the
interdisciplinary care team will engage the beneficiary and his/her family and caregiver(s).
Enter your response to #3 here.
4. If the applicant is delegating the ESRD care, care management, or care coordination services in any capacity
to another organization, the applicant must:
a.
b.
Name the organization(s)
Indicate which aspect(s) of care are delegated to each organization (health plan and delegated
organization(s)), and define the areas for which each party is responsible
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c.
d.
Describe the legal relationships between the applicant and the organization(s), and
Attach a copy of the fully executed contract between the health plan and the organization(s)
Enter your response to #4 here.
5. Provide a list of the contracted nephrologist(s). Beneficiary access to contracted nephrologists must meet
the current HSD criteria.
Name of Contracted Nephrologist(s)
Medicare Provider #
Provider Address
Enter name of contracted
nephrologist(s) here.
Enter Medicare provider # here.
Enter provider address here.
6. Provide a list of the contracted dialysis facility(ies). Beneficiary access to contracted dialysis facilities must
meet the current HSD criteria.
Name of Contracted Dialysis
Medicare Provider #
Facilities Address
Facility(ies)
Enter name of contracted dialysis
facility(ies) here.
Enter Medicare provider # here.
Enter facilities address here.
7. Describe the dialysis options available to beneficiaries (e.g., home dialysis; nocturnal dialysis).
Enter your response to #7 here.
8. Provide a list of the contracted kidney transplant facility(ies).
Name of Contracted Kidney
Medicare Provider #
Transplant Facility(ies)
Enter Name of contracted kidney
transplant facility(ies) here.
Enter Medicare provider # here.
Facilities Address
Enter facilities address here.
9. Describe beneficiary access to contracted kidney transplant facility(ies), including the average distance
beneficiaries in each county served by the applicant’s SNP must travel to reach a contracted kidney transplant
facility. In instances where the contracted kidney transplant facility(ies) are not within the local patterns of
care for a given county, provide a justification for this deviation, and describe the transportation services and
accommodations which will be made available to beneficiaries.
Enter your response to #9 here.
Please use the following table to provide distance information.
County, ST
Average Distance
Enter the service area county and state (County, ST)
Enter the average distance (in miles) beneficiaries must
here.
travel here.
20.
Model of Care Matrix Upload Document
Please complete and upload this document into HPMS per HPMS MA Application User Guide instructions.
Applicant's Contract Name (as provided in HPMS)
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Enter contract name here.
Applicant’s CMS Contract Number
Enter contract number here.
Care Management Plan Outlining the Model of Care
In the following table, list the document, page number, and section of the corresponding description in your care
management plan for each model of care element.
Corresponding Document
Model of Care Elements
Page Number/Section
1. Description of the SNP-specific Target Population
(e.g., Medicaid subset D-SNP, institutional equivalent individuals enrolled
in I-SNP, diabetes C-SNP, or chronic heart failure/cardiovascular C-SNP)
2. Measurable Goals
a. Describe the specific goals including:
• Improving access to essential services such as medical, mental health,
and social services
• Improving access to affordable care
• Improving coordination of care through an identified point of contact
(e.g., gatekeeper)
• Improving seamless transitions of care across healthcare settings,
providers, and health services
• Improving access to preventive health services
• Assuring appropriate utilization of services
• Improving beneficiary health outcomes (specify MAO selected health
outcome measures)
b. Describe the goals as measurable outcomes and indicate how MAO will
know when goals are met
c. Discuss actions MAO will take if goals are not met in the expected time
frame
3. Staff Structure and Care Management Roles
a. Identify the specific employed or contracted staff to perform
administrative functions (e.g., process enrollments, verify eligibility,
process claims, etc.)
b. Identify the specific employed or contracted staff to perform clinical
functions (e.g., coordinates care management, provide clinical care,
educate beneficiaries on self-management techniques, consult on
pharmacy issues, counsel on drug dependence rehab strategies, etc.)
c. Identify the specific employed or contracted staff to perform
administrative and clinical oversight functions (e.g., verifies licensing
and competency, reviews encounter data for appropriateness and
timeliness of services, reviews pharmacy claims and utilization data for
appropriateness, assures provider use of clinical practice guidelines, etc.)
4. Interdisciplinary Care Team (ICT)
a. Describe the composition of the ICT and how the MAO determined the
membership
b. Describe how the MAO will facilitate the participation of the beneficiary
whenever feasible
c. Describe how the ICT will operate and communicate (e.g., frequency of
meetings, documentation of proceedings and retention of records,
notification about ICT meetings, dissemination of ICT reports to all
stakeholders, etc.)
5. Provider Network having Specialized Expertise and Use of Clinical
Practice Guidelines and Protocols
a. Describe the specialized expertise in the MAO’s provider network that
corresponds to the target population including facilities and providers
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(e.g., medical specialists, mental health specialists, dialysis facilities,
specialty outpatient clinics, etc.)
b. Describe how the MAO determined that its network facilities and
providers were actively licensed and competent
c. Describe who determines which services beneficiaries will receive (e.g.,
is there a gatekeeper, and if not, how is the beneficiary connected to the
appropriate service provider, etc.)
d. Describe how the provider network coordinates with the ICT and the
beneficiary to deliver specialized services (e.g., how care needs are
communicated to all stakeholders, which personnel assures follow-up is
scheduled and performed, how it assures that specialized services are
delivered to the beneficiary in a timely and quality way, how reports on
services delivered are shared with the plan and ICT for maintenance of a
complete beneficiary record and incorporation into the care plan, how
services are delivered across care settings and providers, etc.)
e. Describe how the MAO assures that providers use evidence-based
clinical practice guidelines and nationally recognized protocols (e.g.,
review of medical records, pharmacy records, medical specialist reports,
audio/video-conferencing to discuss protocols and clinical guidelines,
written protocols providers send to MAO Medical Director for review,
etc.)
6. Model of Care Training for Personnel and Provider Network
a. Describe how the MAO conducted initial and annual model of care
training including training strategies and content (e.g., printed
instructional materials, face-to-face training, web-based instruction,
audio/video-conferencing, etc.)
b. Describe how the MAO assures and documents completion of training
by the employed and contracted personnel (e.g., attendee lists, results of
testing, web-based attendance confirmation, electronic training record,
etc.)
c. Describe who the MAO identified as personnel responsible for oversight
of the model of care training
d. Describe what actions the MAO will take when the required model of
care training has not been completed (e.g., contract evaluation
mechanism, follow-up communication to personnel/providers,
incentives for training completion, etc.)
7. Health Risk Assessment
a. Describe the health risk assessment tool the MAO uses to identify the
specialized needs of its beneficiaries (e.g., identifies medical,
psychosocial, functional, and cognitive needs, medical and mental health
history, etc.)
b. Describe when and how the initial health risk assessment and annual
reassessment is conducted for each beneficiary (e.g., initial assessment
within 90 days of enrollment, annual reassessment within one year of
last assessment; conducted by phone interview, face-to-face, written
form completed by beneficiary, etc.)
c. Describe the personnel who review, analyze, and stratify health care
needs (e.g., professionally knowledgeable and credentialed such as
physicians, nurses, restorative therapist, pharmacist, psychologist, etc.)
d. Describe the communication mechanism the MAO institutes to notify
the ICT, provider network, beneficiaries, etc. about the health risk
assessment and stratification results (e.g., written notification, secure
electronic record, etc.)
8. Individualized Care Plan
a. Describe which personnel develops the individualized plan of care and
how the beneficiary is involved in its development as feasible
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b.
Describe the essential elements incorporated in the plan of care (e.g.,
results of health risk assessment, goals/objectives, specific services and
benefits, outcome measures, preferences for care, add-on benefits and
services for vulnerable beneficiaries such as disabled or those near the
end-of-life, etc)
c. Describe the personnel who review the care plan and how frequently the
plan of care is reviewed and revised (e.g., developed by the
interdisciplinary care team (ICT), beneficiary whenever feasible, and
other pertinent specialists required by the beneficiary’s health needs;
reviewed and revised annually and as a change in health status is
identified, etc.)
d. Describe how the plan of care is documented and where the
documentation is maintained (e.g., accessible to interdisciplinary team,
provider network, and beneficiary either in original form or copies;
maintained in accordance with industry practices such as preserved from
destruction, secured for privacy and confidentiality, etc.)
e. Describe how the plan of care and any care plan revisions are
communicated to the beneficiary, ICT, MAO, and pertinent network
providers
9. Communication Network
a. Describe the MAO’s structure for a communication network (e.g., webbased network, audio-conferencing, face-to-face meetings, etc.)
b. Describe how the communication network connects the plan, providers,
beneficiaries, public, and regulatory agencies
c. Describe how the MAO preserves aspects of communication as evidence
of care (e.g., recordings, written minutes, newsletters, interactive web
sites, etc.)
d. Describe the personnel having oversight responsibility for monitoring
and evaluating communication effectiveness
10. Care Management for the Most Vulnerable Subpopulations
a. Describe how the MAO identifies its most vulnerable beneficiaries
b. Describe the add-on services and benefits the MAO delivers to its most
vulnerable beneficiaries
11. Performance and Health Outcome Measurement
a. Describe how the MAO will collect, analyze, report, and act on to
evaluate the model of care (e.g., specific data sources, specific
performance and outcome measures, etc.)
b. Describe who will collect, analyze, report, and act on data to evaluate
the model of care (e.g., internal quality specialists, contracted
consultants, etc.)
c. Describe how the MAO will use the analyzed results of the performance
measures to improve the model of care (e.g., internal committee, other
structured mechanism, etc.)
d. Describe how the evaluation of the model of care will be documented
and preserved as evidence of the effectiveness of the model of care (e.g.,
electronic or print copies of its evaluation process, etc.)
e. Describe the personnel having oversight responsibility for monitoring
and evaluating the model of care effectiveness (e.g., quality assurance
specialist, consultant with quality expertise, etc.)
f. Describe how the MAO will communicate improvements in the model
of care to all stakeholders (e.g., a webpage for announcements, printed
newsletters, bulletins, announcements, etc.)
21.
Quality Improvement Program Matrix Upload Document
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Please complete and upload this document into HPMS per HPMS MA Application User Guide
instructions.
Applicant's Contract Name (as provided in HPMS)
Enter contract name here.
Applicant’s CMS Contract Number
Enter contract number here.
Quality Improvement Program Plan
In the following table, list the document, page number, and section of the corresponding description of your
quality improvement program components in your written plan.
Corresponding Document
Quality Improvement Program Components
Page Number/Section
1. Description of the SNP-specific Target Population
a. Identify the SNP-specific target population (e.g., Medicaid subset
D-SNP, institutional equivalent individuals enrolled in I-SNP,
diabetes C-SNP, or chronic heart failure/cardiovascular C-SNP)
b. Describe the purpose of the quality improvement program in
relation to the target population
c. Describe how the MAO identifies and monitors the most
vulnerable members of the population (i.e., frail, disabled, near
the end-of-life, multiple or complex chronic conditions, or
developing ESRD after enrollment) and the quality improvement
activities designed for these individuals.
d. Outline the components of the overall quality improvement
program including the MAO’s internal activities and the
following CMS required activities:
• Health information system to collect, analyze, and report
accurate and complete data
• MAO-determined internal quality improvement activities
• Chronic care improvement program (one or more)
• Quality improvement project (one or more)
• Measurement of the effectiveness of the SNP model of care,
indices of quality, and beneficiary health outcomes
• Collection and reporting of HEDIS measures (NCQA)
• Collection and reporting of Structure and Process measures
(NCQA)
• Participation in HOS survey if enrollment meets threshold
• Participation in CAPHS survey if enrollment meets threshold
(Wilkerson & Associates)
• Collection and reporting of Part C Reporting Elements
(HPMS)
• Collection and Reporting of Part D Medication Therapy
Management data
2. Health Information System
a. Describe the health information system and how the system
enables the MAO to:
• Collect, analyze, and integrate data to conduct the quality
improvement program
• Ensure that data is accurate and complete
• Maintain health information for CMS review as requested
• Conduct annual review of the MAO’s overall quality
improvement program
• Take action to correct problems revealed through complaints
and quality improvement activities
b. Describe how the MAO manages the health information system
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to comply with HIPAA and privacy laws, and professional
standards of health information management
3. MAO-determined Internal Quality Improvement Activities
a. Describe the quality improvement activities the MAO has
designed that address the target population and are not
specifically required by CMS.
b. Describe how the MAO maintains documentation on internal
quality improvement activities and makes it available to CMS if
requested.
4. Chronic Care Improvement Program (CCIP)
a. Describe the chronic care improvement program(s) and how
CCIP(s) relate to the SNP target population
b. Describe how the MAO identifies SNP beneficiaries who would
benefit from participation in the CCIP(s)
c. Describe how the MAO monitors the beneficiaries who
participate in the CCIP(s), and how it evaluates the health
outcomes, quality indices, and/or improved operational systems
post-intervention.
5. Quality Improvement Projects (QIP)
a. Describe the quality improvement project(s) and how QIP(s)
relate to the SNP target population including:
• Clearly defined objectives
• Interventions for SNP target population
• Quality indices and health outcomes written as
measureable outcomes
b. Describe how the MAO identifies SNP beneficiaries who would
benefit from participation in the QIP(s)
c. Describe how the MAO monitors the beneficiaries who
participate in the QIP(s)
d. Describe how it evaluates the health outcomes, quality indices,
and/or improved operational systems post-intervention, and
achieves demonstrable improvement
e. Describe how the MAO conducts systematic and periodic followup to assure improvements are sustained
6. SNP-specific Care Management Measurement
a. Describe how the MAO will evaluate the effectiveness of its
model of care including:
• Methodology
• Specific measurable performance outcomes that
demonstrate improvements (e.g., access to care, beneficiary
health status, staff structure and performance of roles,
health risk assessment and stratification of identified needs,
implementation of care plans, adequacy of provider
network, use of clinical practice guidelines by providers,
adequacy of the provider network, etc.)
b. Describe how the MAO maintains documentation on model of
care evaluation and makes it available to CMS as requested and
during onsite audits.
c. Describe how the MAO determines what actions to take based on
the results of its model of care evaluation.
7. HEDIS and Structure & Process Measures (NCQA)
a. Describe how the MAO collects and reports the required HEDIS
measures and Structure & Process measures to NCQA (Note:
SNPs having 30 or more enrolled members are required to report
these measures)
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b. Describe how the MAO assures accuracy of HEDIS and Structure
& Process measures.
c. Describe how the MAO determines what actions to take based on
the results of HEDIS data and Structure & Process measurement.
8. Health Outcomes Survey - HOS
a. Describe how the MAO participates in reporting HOS (Note:
MAOs having 500 or more enrolled members are required to
report HOS information)
b. Describe how the MAO determines what actions to take based on
the HOS survey results.
9. Consumer Assessment of Healthcare Providers and Systems –
CAHPS Survey (Wilkerson & Associates)
a. Describe how the MAO participates in reporting CAHPS (Note:
MAOs having 600 or more enrolled members are required to
report CAPHS information)
b. Describe how the MAO determines what actions to take based on
the CAHPS survey results.
10. Part C Reporting Elements
a. Describe how the MAO collects, analyzes, and reports Part C
reporting data elements to CMS.
b. Describe how the MAO assures accuracy of Part C reporting data
elements.
c. Describe how the MAO determines what actions to take based on
the results of Part C reporting data elements.
11. Part D Medication Therapy Management Reporting
a. Describe how the MAO collects, analyzes, and reports
Medication Therapy Management measures to CMS.
b. Describe how the MAO assures accuracy of Medication Therapy
Management measures.
c. Describe how the MAO determines what actions to take based on
the results of Medication Therapy Management measurement.
12. Communication on Quality Improvement Program with
Stakeholders
a. Describe how the MAO will facilitate the participation of
providers, the interdisciplinary care team, and
beneficiaries/caregivers in its overall quality improvement
program.
b. Describe how the MAO will communicate improvements in care
management resulting from its overall quality improvement
program to all stakeholders (e.g., a webpage for
announcements, printed newsletters, bulletins, announcements,
etc.)
c. Describe how the MAO maintains documentation on its overall
quality improvement program and makes it available to CMS as
requested and during onsite audits.
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6
APPENDIX II: Employer/Union-Only Group Waiver Plans
(EGWPs) MAO “800 Series”
6.1 Background
The MMA provides employers and unions with a number of options for providing
coverage to their Medicare-eligible members. Under the MMA, these options include
purchasing benefits from sponsors of prescription drug-only plans (PDPs), making
special arrangements with Medicare Advantage Organizations (MAOs) and Section 1876
Cost Plans to purchase customized benefits, including drug benefits, for their members,
and directly contracting with CMS to become Part D or MAO plan sponsors themselves.
Each of these approaches involves the use of CMS waivers authorized under Sections
1857(i) or 1860D-22(b) of the SSA. Under this authority, CMS may waive or modify
requirements that “hinder the design of, the offering of, or the enrollment in” employersponsored group plans. CMS may exercise its waiver authority for PDPs, MAOs and
Cost Plan Sponsors that offer employer/union-only group waiver plans (EGWPs).
EGWPs are also known as “800 series” plans because of the way they are enumerated in
CMS systems.
Which Applicants Should Complete this Appendix?
This appendix is to be used by MAOs seeking to offer the following new “800 series”
EGWPs: Private Fee-For-Service (PFFS) Plans, Local Coordinated Care Plans (CCPs),
Regional Preferred Provider Organization Plans (RPPOs), and Regular Medical Savings
Accounts (MSAs). CMS issues separate contract numbers for each type of offering and
thus a separate application is required for each corresponding contract. However,
Applicants may submit one application to be eligible to offer new MA-only and new
MA-PD EGWPs under the same contract number. All applications are required to be
submitted electronically in the HPMS. Please follow the application instructions below
and submit the required material in support of your application to offer new “800 series”
EGWPs.
For waiver guidance and rules on Part C and Part D Employer contracts, see Chapter 9 of
the MMCM and Chapter 12 of the Prescription Drug Benefit Manual.
6.2
Instructions
•
New MAO applicants seeking to offer new “800 series” EGWPs are Applicants
that have not previously applied to offer plans to individual beneficiaries or “800
series” EGWPs.
Note: All new MAOs intending to offer Part D EGWPs (i.e., MA-PDs) must also
complete the 2014 Solicitation for Applications for New Medicare Advantage
Prescription Drug Plan (MA-PD) Sponsors. The 2014 Solicitation for
Applications for New Medicare Advantage Prescription Drug Plan (MA-PD)
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Sponsors must also be submitted electronically through HPMS. These
requirements are also applicable to new MAOs applying to offer “800 series”
Regular MSA or Demonstration MSA plans that do not intend to offer plans to
individual beneficiaries in 2012. Together these documents will comprise a
completed application for new MAOs. Failure to complete, if applicable, the 2014
Solicitation for Applications for New Medicare Advantage Prescription Drug
Plan (MA-PD) Sponsors, may result in a denial of the EGWP application.
•
Existing MAOs that currently offer plans to individual beneficiaries under an
existing contract but have not previously applied to offer EGWPs (MA-only or
MA-PD) under this same contract.
Note: Existing MAOs are only required to complete this appendix.
Separate Applications Required For Each Contract Number
A separate application must be submitted for each contract number under which the
MAO Applicant is applying to offer new “800 series” EGWPs.
6.3
Request for Additional Waivers/Modification of Requirements (Optional)
As a part of the application process, Applicants may submit individual
waiver/modification requests to CMS. The Applicant should submit this additional
waiver/modification request as an upload via HPMS to the Attestation Waiver Request in
the appropriate MA or Part D supplemental upload pages.
These requests must be identified as requests for additional waivers/modifications and
must fully address the following items:
•
Specific provisions of existing statutory, regulatory, and/or CMS policy
requirement(s) the entity is requesting to be waived/modified (please identify the
specific requirement (e.g., “42 CFR § 422.66,” or “Section 40.4 of Chapter 2 of
the MMCM and whether you are requesting a waiver or a modification of these
requirements);
•
How the particular requirements hinder the design of, the offering of, or the
enrollment in, the employer-sponsored group plan;
•
Detailed description of the waiver/modification requested, including how the
waiver/modification will remedy the impediment (i.e., hindrance) to the design of,
the offering of, or the enrollment in, the employer-sponsored group plan;
•
Other details specific to the particular waiver/modification that would assist CMS
in the evaluation of the request; and
•
Contact information (contract number, name, position, phone, fax and email
address) of the person who is available to answer inquiries about the
waiver/modification request.
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6.4
Attestations
EGWP Attestation for Contract _________
1. MSA Applicants:
• If Applicant is seeking to offer MSA “800 series” EGWPs, Applicant may
designate national service areas and provide coverage to employer group
members wherever they reside (i.e., nationwide). Note that CMS has not
issued any waiver permitting MAOs to offer non-calendar year MSA plans.
Therefore, MAOs may only offer calendar year MSA plans.
Network PFFS Applicants:
• If Applicant is seeking to offer individual plans in any part of a state,
Applicant may designate statewide service areas for its “800-series” plan of
the same type (i.e. HMO, PPO or PFFS) and provide coverage to employer
group members residing anywhere in the entire state. Note that all employer
PFFS plans must be network based.
For Local CCP Applicants:
• If Applicant is seeking to offer individual plans in any part of a state, the
Applicant may designate statewide service areas and provide coverage to
employer group members residing anywhere in the entire state.
However, to enable employers and unions to offer CCPs to all their Medicare eligible
retirees wherever they reside, an MAO offering a local CCP in a given service area (i.e., a
state) can extend coverage to an employer’s or union sponsor’s beneficiaries residing
outside of that service area when the MAO, either by itself or through partnerships with
other MAOs, is able to meet CMS provider network adequacy requirements and provide
consistent benefits to those beneficiaries. Applicants who are eligible for this waiver at
the time of application or who may become eligible at any time during the contract year
are strongly encouraged to designate their service area broadly (e.g., multiple states,
national) to allow for the possibility of enrolling members during the contract year if
adequate networks are in place. No mid-year service area expansions will be
permitted. Applicants offering both individual and “800 series” plans will be required to
have Part C or D networks in place for those designated EGWP service areas outside of
their individual plan service areas.
RPPO Applicants:
• Applicants offering individual plans in any region may provide coverage to
employer group members residing throughout the entire region (i.e., RPPOs
must have the same service area for its EGWPs as for its individual plans).
I certify that I am an authorized representative, officer, chief executive officer, or
general partner of the business organization that is applying for qualification to offer
EGWPs in association with my organization’s MA contract with CMS. I have read,
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understand, and agree to comply with the above statement about service areas. If I need
further information, I will contact one of the individuals listed in the instructions for this
appendix.
{Entity MUST complete to be considered a complete application.}
2. CERTIFICATION
Note: Any specific certifications below that reference Part D are not applicable to MAO
Applicants applying to offer an MSA product because these entities cannot offer Part D
under these contracts. Entities can offer Part D benefits through a separate standalone
Prescription Drug Plan (PDP); however, a separate application is required to offer “800
series” PDPs.
All provisions of the 2014 MA Applications and the 2014 Solicitation for Applications
for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors apply to all
employer/union-group waiver plan benefit packages offered by MAOs except where the
provisions are specifically modified and/or superseded by particular employer/union-only
group waiver guidance, including those waivers/modifications set forth below.
For existing MAOs, this appendix comprises the entire “800 series” EGWP application
for MAOs.
I, the undersigned, certify to the following:
1) Applicant is applying to offer new employer/union-only group waiver (“800
series”) plans and agrees to be subject to and comply with all CMS
employer/union-only group waiver guidance.
2) New MAO Applicants seeking to offer an EGWP (“800 series” plan) must submit
and complete the entire EGWP application for MAOs which consists of: this
appendix, along with the 2014 MA Application and the 2014 Solicitation for
Applications for New Medicare Advantage Prescription Drug Plan (MA-PD)
Sponsors (if applicable).
3) Applicant agrees to restrict enrollment in its EGWPs to those Medicare eligible
individuals eligible for the employer’s/union’s employment-based group
coverage. (See 42 CFR section 422.106(d)(2))
4) Applicant understands and agrees that it is not required to submit a 2014 Part D
bid (i.e., bid pricing tool) in order to offer its EGWPs. (Section 2.7 of the 2014
Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD)
Sponsors)
5) In order to be eligible for the CMS retail pharmacy access waiver of 42 CFR §
423.120(a)(1), Applicant attests that its retail pharmacy network is sufficient to
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meet the needs of its enrollees throughout the employer/union-only group waiver
service area, including situations involving emergency access, as determined by
CMS. Applicant acknowledges and understands that CMS reviews the adequacy
of the Applicant’s pharmacy networks and may potentially require expanded
access in the event of beneficiary complaints or for other reasons it determines in
order to ensure that the Applicant’s network is sufficient to meet the needs of its
employer group population. (See the 2014 Solicitation for New Medicare
Advantage Prescription Drug Plan (MA-PD) Sponsors)
6) MAO Applicant understands and agrees that as a part of the underlying
application, it submits a Part D retail pharmacy network list, and other pharmacy
access submissions (mail order, home infusion, long-term care, I/T/U) in the 2014
Solicitation for Applications for New Medicare Advantage Prescription Drug Plan
(MA-PD) Sponsors for its designated EGWP service area at the time of
application.
7) Applicant understands that its EGWPs are not included in the processes for autoenrollment (for full-dual eligible beneficiaries) or facilitated enrollment (for other
low income subsidy eligible beneficiaries).
8) Applicant understands that CMS has waived the requirement that the EGWPs
must provide beneficiaries the option to pay their premiums through Social
Security withholding. Thus, the premium withhold option will not be available for
enrollees in 42 CFR § 422.64 and 42 CFR § 423.48 to submit information to
CMS, including the requirement to submit information (e.g., pricing and
pharmacy network information) to be publicly reported on www.medicare.gov,
Medicare Plan Finder (“MPF”). Applicant’s EGWPs. (Sections 3.6.A10 and
3.24.A2-A4 of the 2014 Solicitation for New Medicare Advantage Prescription
Drug Plan (MA-PD) Sponsors)
9) Applicant understands that dissemination/disclosure materials for its EGWPs are
not subject to the requirements contained in 42 CFR § 422.2262 or 42 CFR §
423.2262 to be submitted for review and approval by CMS prior to use. However,
Applicant agrees to submit these materials to CMS at the time of use in
accordance with the procedures outlined in Chapter 9 of the MMCM. Applicant
also understands CMS reserves the right to review these materials in the event of
beneficiary complaints or for any other reason it determines to ensure the
information accurately and adequately informs Medicare beneficiaries about their
rights and obligations under the plan. (See the 2014 Solicitation for New
Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)
10) Applicant understands that its EGWPs is not subject to the requirements regarding
the timing for issuance of certain disclosure materials, such as the Annual Notice
of Change/ Evidence of Coverage (ANOC/EOC), Summary of Benefits (SB),
Formulary, and LIS rider when an employer’s or union’s open enrollment period
does not correspond to Medicare’s Annual Coordinated Election Period. For these
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employers and unions, the timing for issuance of the above disclosure materials
should be appropriately based on the employer/union sponsor’s open enrollment
period. For example, the Annual Notice of Change/Evidence of Coverage
(ANOC/EOC), Summary of Benefits (SB), LIS rider, and Formulary are required
to be received by beneficiaries no later than 15 days before the beginning of the
employer/union group health plan’s open enrollment period. The timing for other
disclosure materials that are based on the start of the Medicare plan (i.e., calendar)
year should be appropriately based on the employer/union sponsor’s plan year.
(Section 3.14.A.11 of the 2014 Solicitation for New Medicare Advantage
Prescription Drug Plan (MA-PD) Sponsors)
11) Applicant understands that the dissemination/disclosure requirements set forth in
42 CFR § 422.111 and 42 CFR § 423.128 do not apply to its EGWPs when the
employer/union sponsor is subject to alternative disclosure requirements (e.g., the
Employee Retirement Income Security Act of 1974 (“ERISA”)) and complies
with such alternative requirements. Applicant complies with the requirements for
this waiver contained in employer/union-only group waiver guidance, including
those requirements contained in Chapter 9 of the MMCM. (Sections 3.14.A.1-2, 9
of the 2014 Solicitation for New Medicare Advantage Prescription Drug Plan
(MA-PD) Sponsors)
12) Applicant understands that its EGWPs are not subject to the Part D beneficiary
customer service call center hours and call center performance requirements.
Applicant has a sufficient mechanism is available to respond to beneficiary
inquiries and provides customer service call center services to these members
during normal business hours. However, CMS may review the adequacy of these
call center hours and potentially require expanded beneficiary customer service
call center hours in the event of beneficiary complaints or for other reasons in
order to ensure that the entity’s customer service call center hours are sufficient to
meet the needs of its enrollee population. (Section 3.14.A.6 of the 2014
Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD)
Sponsors)
13) Applicant understands that its EGWPs are not subject to the requirements
contained in 42 CFR § 422.64 and 42 CFR § 423.48 to submit information to
CMS, including the requirements to submit information (e.g., pricing and
pharmacy network information) to be publicly reported on www.medicare.gov,
Medicare Plan Finder (“MPF”). (Sections 3.8.A and 3.17.A.14 of the 2014
Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD)
Sponsors)
14) In order to be eligible for the CMS service area waiver for Local CCPs that allows
an MAO to extend coverage to employer group members outside of its individual
plan service area, Applicant attests it has at the time of application or will have at
the time of enrollment, Part C networks adequate to meet CMS requirements and
is able to provide consistent benefits to those beneficiaries, either by itself or
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through partnerships with other MAOs. If Applicant is also applying to offer Part
D, Applicant attests that such expanded service areas will have convenient Part D
pharmacy access sufficient to meet the needs of these enrollees.
15) MSA employer/union-only group waiver plan Applicants understand that they
will be permitted to enroll members through a Special Election Period (SEP) as
specified in Chapter 2, Section 30.4.4.1, of the MMCM.
16) This Certification is deemed to incorporate any changes that are required by
statute to be implemented during the term of the contract, and any regulations and
policies implementing or interpreting such statutory provisions.
17) I have read the contents of the completed application and certify that the
information contained herein is true, correct, and complete. If I become aware that
any information in this appendix is not true, correct, or complete, I agree to notify
CMS immediately and in writing.
18) I authorize CMS to verify the information contained herein. I agree to notify CMS
in writing of any changes that may jeopardize my ability to meet the
qualifications stated in this appendix prior to such change or within 30 days of the
effective date of such change. I understand that such a change may result in
revocation of the approval.
19) I understand that in accordance with 18 U.S.C.§. 1001, any omission,
misrepresentation or falsification of any information contained in this appendix or
contained in any communication supplying information to CMS to complete or
clarify this appendix may be punishable by criminal, civil, or other administrative
actions including revocation of approval, fines, and/or imprisonment under
Federal law.
20) I acknowledge that I am aware that there is operational policy guidance, including
the forthcoming Call Letter, relevant to this appendix that is posted on the CMS
website and that it is continually updated. Organizations submitting an application
in response to this solicitation acknowledge that they will comply with such
guidance at the time of application submission.
I certify that I am an authorized representative, officer, chief executive officer, or
general partner of the business organization that is applying for qualification to offer
EGWPs in association with my organization’s MA contract with CMS. I have read
and agree to comply with the above certifications.
{Entity MUST check box to be considered a complete application.}
{Entity MUST create 800-series PBPs during plan creation and designate EGWP
service areas.}
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7 APPENDIX III: Employer/Union Direct Contract for MA
7.1
Background
The MMA provides employers and unions with a number of options for providing
medical and prescription drug coverage to their Medicare-eligible employees, members,
and retirees. Under the MMA, these options include making special arrangements with
MAOs and Section 1876 Cost Plans to purchase customized benefits, including drug
benefits, for their members; purchasing benefits from sponsors of standalone prescription
drug plans (PDPs); and directly contracting with CMS to become a Direct Contract MA,
MA-PD or PDP sponsor themselves. Each of these approaches involves the use of CMS
waivers authorized under Section 1857(i) or 1860D-22(b) of the SSA. Under this
authority, CMS may waive or modify requirements that “hinder the design of, the
offering of, or the enrollment in” employer or union-sponsored group plans.
Which Applicants Should Complete This Appendix?
This appendix is to be used by employers or unions seeking to contract directly with
CMS to become a Direct Contract MAO for its Medicare-eligible active employees
and/or retirees. A Direct Contract MAO can be a:
i. Coordinated Care Plan (CCP) or
ii. Private Fee-For-Service (PFFS) Plan.
Please follow the application instructions below and submit the required material in
support of your application.
7.2
Instructions
All Direct Contract MA Applicants must complete and submit the following:
(1) The 2014 MA Application. This portion of the appendix is submitted electronically
through the HPMS.
(2) The 2014 Part C Financial Solvency & Capital Adequacy Documentation Direct
Contract MA Application. This portion of the appendix is submitted electronically
through HPMS.
(3) The 2014 Direct Contract MA Attestations. This portion of the appendix is submitted
electronically through HPMS. A copy of these attestations is included with this appendix.
(4) The 2014 Request for Additional Waivers/Modification of Requirements (Optional).
This portion of the application is submitted electronically through HPMS. This
submission is optional and should be submitted only if the Direct Contract MA Applicant
is seeking new waivers or modifications of CMS requirements.
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All of the above enumerated submissions will comprise a completed application for new
Direct Contract MA Applicants. Failure to complete and submit item numbers 1 through
3 above will result in a denial of the Direct Contract MA application (item number 4 is
optional, as noted above).
Please note that in addition to this Appendix, all Direct Contract MA Applicants
seeking to contract directly with CMS to offer Part D coverage must also complete
the 2014 Solicitation for Applications for New Medicare Advantage Prescription Drug
Plan (MA-PD) Sponsors and the 2014 Solicitation for Applications for New
Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MAPD) Sponsors.
7.3
Request for Additional Waivers/Modification of Requirements (Optional)
Applicants may submit individual waiver/modification requests to CMS. The Applicant
should submit these additional waiver/modifications via hard copy in accordance with the
instructions above.
These requests must be identified as requests for additional waivers/modifications and
must fully address the following items:
•
Specific provisions of existing statutory, regulatory, and/or CMS policy
requirement(s) the entity is requesting to be waived/modified (please identify the
specific requirement (e.g., “42 CFR § 422.66,” or “Section 40.4 of Chapter 2 of
the MMCM) and whether you are requesting a waiver or a modification of these
requirements);
•
How the particular requirements hinder the design of, the offering of, or the
enrollment in, the employer-sponsored group plan;
•
Detailed description of the waiver/modification requested including how the
waiver/modification will remedy the impediment (i.e., hindrance) to the design of,
the offering of, or the enrollment in, the employer-sponsored group plan;
•
Other details specific to the particular waiver/modification that would assist CMS
in the evaluation of the request; and
•
Contact information (contract number, name, position, phone, fax and email
address) of the person who is available to answer inquiries about the
waiver/modification request.
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7.4
Attestations
Direct Contract MA Attestations
1.
SERVICE AREA REQUIREMENTS
In general, MAOs can cover beneficiaries only in the service areas in which they are
licensed and approved by CMS to offer benefits. CMS has waived these requirements for
Direct Contract MA Applicants (Direct Contract CCP and/or Direct Contract PFFS
MAOs). Applicants can extend coverage to all of their Medicare-eligible
employees/retirees, regardless of whether they reside in one or more other MAO regions
in the nation. In order to provide coverage to retirees wherever they reside, Direct
Contract MA Applicants must set their service area to include all areas where retirees
may reside during the plan year (no mid-year service area expansions will be
permitted).
Direct Contract MA Applicants that offer Part D (i.e., MA-PDs) will be required to
submit pharmacy access information for the entire defined service area during the
application process and demonstrate sufficient access in these areas in accordance with
employer group waiver pharmacy access policy.
I certify that I am an authorized representative, officer, chief executive officer, or
general partner of the business organization that is applying for qualification to offer a
Direct Contract MA plan. I have read, understand, and agree to comply with the above
statement about service areas. If I need further information, I will contact one of the
individuals listed in the instructions for this appendix.
{Entity MUST check box for their application to be considered complete.}
2.
CERTIFICATION
All provisions of the 2014 MA Application apply to all plan benefit packages offered by
Direct Contract MAO except where the provisions are specifically modified and/or
superseded by particular employer/union-only group waiver guidance, including those
waivers/modifications set forth below (specific sections of the 2014 MA Application that
have been waived or modified for new Direct Contract MAOs are noted in parentheses).
I, the undersigned, certify to the following:
1) Applicant is applying to offer new employer/union Direct Contract MA plans and
agrees to be subject to and comply with all CMS employer/union-only group waiver
guidance.
2) Applicant understands and agrees that it must complete and submit the 2014 MA
Application in addition to this 2014 Initial Application for Employer/Union Direct
Contract MAOs application in its entirety, and the Part C Financial Solvency & Capital
Adequacy Documentation for Direct Contract Applicants).
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Note: Applicant understands and agrees that to offer prescription drug benefits, it must
also submit the 2014 Solicitation for Applications for New Medicare Advantage
Prescription Drug Plan (MA-PD) Sponsors and the 2014 Solicitation for Applications for
New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MAPD) Sponsors.
3) In general, an MAO must be organized and licensed under state law as a risk-bearing
entity eligible to offer health insurance or health benefits coverage in each state in which
it offers coverage (42 CFR § 422.400). However, CMS has waived the state licensing
requirement for all Direct Contract MAOs. As a condition of this waiver, Applicant
understands that CMS will require such entities to meet the financial solvency and capital
adequacy standards contained in this appendix. (See State Licensure Section of the 2014
MA Application)
4) Applicant agrees to restrict enrollment in its Direct Contract MA plans to those
Medicare-eligible individuals eligible for the employer’s/union’s employment-based
group coverage.
5) In general, MAOs must meet minimum enrollment standards as set forth in 42 CFR §
422.514(a). Applicant understands that it will not be subject to the minimum enrollment
requirements set forth in 42 CFR § 422.514(a).
6) Applicant understands that dissemination/disclosure materials for its Direct Contract
MAO plans are not subject to the requirements contained in 42 CFR § 422.2262 to be
submitted for review and approval by CMS prior to use. However, Applicant agrees to
submit these materials to CMS at the time of use in accordance with the procedures
outlined in Chapter 9 of the MMCM. Applicant also understands that CMS reserves the
right to review these materials in the event of beneficiary complaints, or for any other
reason it determines, to ensure the information accurately and adequately informs
Medicare beneficiaries about their rights and obligations under the plan. (See Medicare
Operations Section of the 2014 MA Application)
7) Applicant understands that its Direct Contract MA plans will not be subject to the
requirements regarding the timing for issuance of certain disclosure materials, such as the
Annual Notice of Change/ Evidence of Coverage (ANOC/EOC), Summary of Benefits
(SB), Formulary, and LIS rider when an employer’s or union’s open enrollment period
does not correspond to Medicare’s Annual Coordinated Election Period. For these
employers and unions, the timing for issuance of the above disclosure materials should be
appropriately based on the employer/union sponsor’s open enrollment period. For
example, the Annual Notice of Change/Evidence of Coverage (ANOC/EOC), Summary
of Benefits (SB), LIS rider, and Formulary are required to be received by beneficiaries no
later than 15 days before the beginning of the employer/union group health plan’s open
enrollment period. The timing for other disclosure materials that are based on the start of
the Medicare plan (i.e., calendar) year should be appropriately based on the
employer/union sponsor’s plan year. (See Medicare Operations Section of the 2014 MA
Application)
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8) Applicant understands that the dissemination/disclosure requirements set forth in 42
CFR § 422.111 will not apply to its Direct Contract MA plans when the employer/union
sponsor is subject to alternative disclosure requirements (e.g., ERISA) and complies with
such alternative requirements. Applicant agrees to comply with the requirements for this
waiver contained in employer/union-only group waiver guidance, including those
requirements contained in Chapter 9 of the MMCM. (See Medicare Operations Section
3.13 of the 2014 MA Application)
9) Applicant understands that its Direct Contract MA plans are not subject to the MA
beneficiary customer service call center hours and call center performance requirements.
Applicant has a sufficient mechanism available to respond to beneficiary inquiries
and will provide customer service call center services to these members during normal
business hours. However, CMS may review the adequacy of these call center hours and
potentially require expanded beneficiary customer service call center hours in the event
of beneficiary complaints or for other reasons in order to ensure that the entity’s customer
service call center hours are sufficient to meet the needs of its enrollee population. (See
Medicare Operations Section of the 2014 MA Application)
10) Applicant understands that its Direct Contract MA plans are not subject to the
requirements contained in 42 CFR § 422.64 to submit information to CMS, including the
requirements to submit information (e.g., pricing and provider network information) to be
publicly reported on http://www.medicare.gov (Medicare Options Compare).
11) Applicant understands that the management and operations requirements of 42 CFR §
422.503(b)(4)(i)-(iii) are waived if the employer or union (or to the extent applicable, the
business associate with which it contracts for benefit services) is subject to ERISA
fiduciary requirements or similar state or federal law standards. However, such entities
(or their business associates) are not relieved from the record retention standards
applicable to other MAOs set forth in 42 CFR 422.504(d). (See Fiscal Soundness Section
of the 2014 MA Application)
12) In general, MAOs must report certain information to CMS, to their enrollees, and to
the general public (such as the cost of their operations and financial statements) under 42
CFR § 422.516(a). Applicant understands that in order to avoid imposing additional and
possibly conflicting public disclosure obligations that would hinder the offering of
employer sponsored group plans, CMS modifies these reporting requirements for Direct
Contract MAOs to allow information to be reported to enrollees and to the general public
to the extent required by other laws (including ERISA or securities laws) or by contract.
13) In general, MAOs are not permitted to enroll beneficiaries who do not meet the MA
eligibility requirements of 42 CFR § 422.50(a), which include the requirement to be
entitled to Medicare Part A. (42 CFR § 422.50(a)(1)). Applicant understands that under
certain circumstances, as outlined in section 30.1.4 of Chapter 9 of the MMCM, Direct
Contract MAOs are permitted to enroll beneficiaries who are not entitled to Medicare
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Part A into Part B-only plan benefit packages. (See Medicare Operations Section of the
2014 MA Application)
14) In general, MAOs are not permitted to enroll beneficiaries who have end-stage renal
disease (ESRD). Applicant understands that under certain circumstances, as outlined in
section 20.2.3 of Chapter 2 of the MMCM, Direct Contract MAOs are permitted to enroll
beneficiaries who have ESRD. (See Medicare Operations Section of the 2014 MA
Application)
15) This Certification is deemed to incorporate any changes that are required by statute to
be implemented during the term of the contract, and any regulations and policies
implementing or interpreting such statutory provisions.
16) I have read the contents of the completed application and the information contained
herein is true, correct, and complete. If I become aware that any information in this
appendix is not true, correct, or complete, I agree to notify CMS immediately and in
writing.
17) I authorize CMS to verify the information contained herein. I agree to notify CMS in
writing of any changes that may jeopardize my ability to meet the qualifications stated in
this appendix prior to such change or within 30 days of the effective date of such change.
I understand that such a change may result in revocation of the approval.
18) I understand that in accordance with 18 U.S.C.§.§ 1001, any omission,
misrepresentation or falsification of any information contained in this appendix or
contained in any communication supplying information to CMS to complete or clarify
this appendix may be punishable by criminal, civil, or other administrative actions,
including revocation of approval, fines, and/or imprisonment under Federal law.
19) I acknowledge that I am aware that there is operational policy guidance, including the
forthcoming Call Letter, relevant to this appendix that is posted on the CMS website and
that it is continually updated. Organizations submitting an application in response to this
solicitation acknowledge that they will comply with such guidance should they be
approved to offer employer/union-only group waiver plans in association with the
organization’s MA contract with CMS.
I certify that I am an authorized representative, officer, chief executive officer, or
general partner of the business organization that is applying for qualification to offer a
Direct Contract MAO plan. I have read and agree to comply with the above certifications.
{Entity MUST check box for their application to be considered complete.}
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7.5
Part C Financial Solvency & Capital Adequacy Documentation For Direct
Contract MAO Applicants:
Background and Instructions
An MAO generally must be licensed by at least one state as a risk-bearing entity
(42 CFR 422.400). CMS has waived the requirement for Direct Contract MAOs.
Direct Contract MAOs are not required to be licensed, but must meet CMS MA
Part C financial solvency and capital adequacy requirements. Each Direct
Contract MAO Applicant must demonstrate that it meets the financial solvency
requirements set forth in this appendix and provide all required information set
forth below. CMS has the discretion to approve, on a case-by-case basis, waivers
of such requirements if the Direct Contract MAO can demonstrate that its fiscal
soundness is commensurate with its financial risk and that through other means
the entity can ensure that claims for benefits paid for by CMS and beneficiaries
will be covered. In all cases, CMS will require that the employers’/unions’
contracts and sub-contracts provide beneficiary hold-harmless provisions.
The information required in this Appendix must be submitted in hardcopy in
accordance with the instructions above.
I. EMPLOYER/UNION ORGANIZATIONAL INFORMATION
A. Complete the information in the table below.
INDENTIFY YOUR ORGANIZATION BY PROVIDING THE FOLLOWING INFORMATION:
Type of DIRECT CONTRACT MEDICARE ADVANTAGE PLAN requested (Check all that apply):
Coordinated Care Plan :
HMO/POS
LPPO
Open Access (Non-Network) PFFS Plan
Contracted Network PFFS Plan
Organization’s Full Legal Name:
Full Address Of Your Organization’s Headquarters (Street, City, State, Zip):
Tax Status: For Profit
Not For Profit
Is Applicant Subject To ERISA? Yes
No
Type Of Entity (Check All That Apply) :
Employer
Labor Union
Publicly-Traded Corporation
Fund Established by One or More Employers or Labor Organizations
Privately-Held Corporation
Government
Church Group
Other (list Type) _____________________________________________
Name of Your Organization’s Parent Organization, if any:
State in Which your Organization is Incorporated or Otherwise Organized to do Business:
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B. Summary Description
Briefly describe the organization in terms of its history and its present operations. Cite
significant aspects of its current financial, general management, and health services
delivery activities. Please include the following:
A.
The size of the Medicare population currently served by the Applicant,
and if any, the maximum number of Medicare beneficiaries that could be
served by a Direct Contract MAO.
B. The manner in which benefits are currently provided to the current
Medicare population served by the Applicant, and if any, the number of
beneficiaries in each employer sponsored group option currently made
available by the Direct Contract MAO Applicant and how these options
are currently funded (i.e., self-funded or fully insured).
C. The current benefit design for each of the options described in B above,
including premium contributions made by the employer and/or the retiree,
deductibles, co-payments, or co-insurance, etc. (Applicant may attach a
summary plan description of its benefits or other relevant materials
describing these benefits.)
D. Information about other Medicare contracts held by the Applicant, (i.e.,
1876, fee for service, PPO, etc.). Provide the names and contact
information for all CMS personnel with whom Applicant works on their
other Medicare contract(s).
E. The factors that are most important to Applicant in deciding to apply to
become a Direct Contract MAO for its retirees and how becoming a Direct
Contract MAO will benefit the Applicant and its retirees.
C. If the Applicant is a state agency, labor organization, or a trust established by one
or more employers or labor organizations, Applicant must provide the required
information listed below:
State Agencies:
If Applicant is a state agency, instrumentality or subdivision, please provide the
relationship between the entity that is named as the Direct Contract MAO Applicant and
the state or commonwealth with respect to which the Direct Contract MAO Applicant is
an agency, instrumentality or subdivision. Also, Applicant must provide the source of
Applicant’s revenues, including whether Applicant receives appropriations and/or has the
authority to issue debt.
Labor Organizations:
If Applicant is a labor organization, including a fund or trust, please provide the
relationship (if any) between Applicant and any other related labor organizations such as
regional, local or international unions, or welfare funds sponsored by such related labor
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organizations. If Applicant is a jointly trusted Taft-Hartley fund, please include the names
and titles of labor-appointed and management-appointed trustees.
Trusts:
If Applicant is a trust such as a voluntary employee beneficiary association under Section
501(c)(9) of the Internal Revenue Code, please provide the names of the individual
trustees and the bank, trust company or other financial institution that has custody of
Applicant’s assets.
D. Policymaking Body (42 CFR 422.503(b)(4)(i)-(iii)
In general, an entity seeking to contract with CMS as a Direct Contract MAO must have
policymaking bodies exercising oversight and control to ensure actions are in the best
interest of the organization and its enrollees, appropriate personnel and systems relating
to medical services, administration and management, and at a minimum an executive
manager whose appointment and removal are under the control of the policymaking
body.
An employer or union directly contracting with CMS as a Direct Contract MAO may be
subject to other, potentially different standards governing its management and operations,
such as the Employee Retirement Income Security Act of 1974 (“ERISA”) fiduciary
requirements, state law standards, and certain oversight standards created under the
Sarbanes-Oxley Act. In most cases, they will also contract with outside vendors (i.e.,
business associates) to provide health benefit plan services. To reflect these issues and
avoid imposing additional (and potentially conflicting) government oversight that may
hinder employers and unions from considering applying to offer Direct Contract MA
Plans, the management and operations requirements under 42 CFR 422.503(b)(4)(i)-(iii)
are waived if the employer or union (or to the extent applicable, the business associate
with which it contracts for health benefit plan services) is subject to ERISA fiduciary
requirements or similar state or federal laws and standards. However, such entities (or
their business associates) are not relieved from the record retention standards applicable
to other MAOs.
In accordance with the terms of this waiver, please provide the following information:
A. List the members of the organization's policymaking body (name, position,
address, telephone number, occupation, term of office and term expiration date).
Indicate whether any of the members are employees of the Applicant.
B. If the Applicant is a line of business rather than a legal entity, does the Board of
Directors of the corporation serve as the policymaking body of the organization?
If not, describe the policymaking body and its relationship to the corporate
board.
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C. Does the Federal Government or a state regulate the composition of the
policymaking body? If yes, please identify all Federal and state regulations that
govern your policymaking body (e.g., ERISA).
II. FINANCIAL SOLVENCY
A. Please provide a copy of the Applicant’s most recent independently certified
audited statements.
B. Please submit an attestation signed by the Chairman of the Board, Chief
Executive Officer and Chief Financial Officer or Trustee or other equivalent
official attesting to the following:
1. The Applicant will maintain a fiscally sound operation and will notify CMS
within 10 business days if it becomes fiscally unsound during the contract
period.
2. The Applicant is in compliance with all applicable Federal and state
requirements and is not under any type of supervision, corrective action
plan, or special monitoring by the Federal or state government or a state
regulator. Note: If the Applicant cannot attest to this compliance, a
written statement of the reasons must be provided.
III. FINANCIAL DOCUMENTATION
A. Minimum Net Worth at the Time of Application - Documentation of
Minimum Net Worth
At the time of application, the Applicant must demonstrate financial solvency
through furnishing two years of independently audited financial statements to
CMS. These financial statements must demonstrate a required minimum net
worth at the time of application of the greater of $3.0 million or the number of
expected individuals to be covered under the Direct Contract MAO Plan times (X)
$800.00. Complete the following:
1. Minimum Net Worth: $
2. Number of expected individuals to be covered under the Direct Contract
MAO Plan times (X) $800.00 = $______________________.
Note: If the Direct Contract MAO Applicant is also applying to offer a Direct
Contract MAO that provides Part D coverage (i.e., MA-PD), it must
complete and submit the corresponding Direct Contract MA-PD application
with this appendix and meet the Part D Minimum Net Worth requirements
stated in the separate Direct Contract MA-PD application.
If the Applicant has not been in operation at least twelve months, it may choose
to: 1) obtain independently audited financial statements for a shorter time period;
or 2) demonstrate that it has the minimum net worth through presentation of un2014 Part C Application
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audited financial statements that contain sufficient detail to allow CMS to verify
the validity of the financial presentation. The un-audited financial statements must
be accompanied by an actuarial opinion from a qualified actuary regarding the
assumptions and methods used in determining loss reserves, actuarial liabilities
and related items.
A “qualified actuary” for purposes of this appendix means a member in good
standing of the American Academy of Actuaries, a person recognized by the
Academy as qualified for membership, or a person who has otherwise
demonstrated competency in the field of actuarial science and is satisfactory to
CMS.
If the Direct Contract MAO Applicant’s auditor is not one of the 10 largest
national accounting firms in accordance with the list of the 100 largest public
accounting firms published by the CCH Public Accounting Report, the Applicant
should enclose proof of the auditor’s good standing from the relevant state board
of accountancy.
A. Minimum Net Worth On and After Effective Date of Contract
The Applicant must have net worth as of the effective date of the contract of the
greatest of the following financial thresholds; $3.0 Million; or, an amount equal
to eight percent of annual health care expenditures, using the most recent financial
statements filed with CMS; or the number of expected individuals to be covered
under the Direct Contract MAO Plan times (X) $800.00.
B. Liquidity at the Time of Application ($1.5 Million)
The Applicant must have sufficient cash flow to meet its financial obligations as
they become due. The amount of the minimum net worth requirement to be met
by cash or cash equivalents is $1.5 Million. Cash equivalents are short-term
highly liquid investments that can be readily converted to cash. To be classified as
cash equivalents, investments must have a maturity date not longer than three
months from the date of purchase.
Note: If the Direct Contract MAO Applicant is also applying to offer a Direct
Contract MA Plan that provides Part D coverage (i.e., MA-PD), it must
complete and submit the corresponding Direct Contract MA-PD application
and meet the Part D Liquidity requirements stated in the separate Direct
Contract MA-PD application.
C. Liquidity On and After Effective Date of Contract
After the effective date of the contract, an Applicant must maintain the greater of
$1.5 Million or 40 percent of the minimum net worth requirement outlined in
Section III.B above in cash or cash equivalents.
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In determining the ability of an Applicant to meet the requirements of this
paragraph D, CMS will consider the following:
1. The timeliness of payment;
2. The extent to which the current ratio is maintained at 1:1 or greater, or
whether there is a change in the current ratio over a period of time; and
3. The availability of outside financial resources.
CMS may apply the following corresponding corrective remedies:
1. If a Direct Contract MAO fails to pay obligations as they become due, CMS
will require the Direct Contract MAO to initiate corrective action to pay all
overdue obligations.
2. CMS may require the Direct Contract MAO to initiate corrective action if
either of the following is evident:
(a) The current ratio declines significantly; or
(b) There is a continued downward trend in the current ratio.
The corrective action may include a change in the distribution of assets, a
reduction of liabilities, or alternative arrangements to secure additional
funding to restore the current ratio to at least 1:1.
3. If there is a change in the availability of outside resources, CMS will require
the Direct Contract MAO to obtain funding from alternative financial
resources.
D. Methods of Accounting
A Direct Contract MAO Applicant generally must use the standards of Generally
Accepted Accounting Principles (GAAP). GAAP are those accounting principles
or practices prescribed or permitted by the Financial Accounting Standards Board.
However, a Direct Contract MAO whose audited financial statements are
prepared using accounting principles or practices other than GAAP, such as a
governmental entity that reports in accordance with the principles promulgated by
the Governmental Accounting Standards Board (GASB), may utilize such
alternative standard.
E. Bonding and Insurance
An Applicant may request a waiver in writing of the bonding and/or insurance
requirements set forth at 42 CFR 422.503(b)(4)(iv) and (v). Relevant
considerations will include demonstration that either or both of the foregoing
requirements are unnecessary based on the entity’s individualized circumstances,
including maintenance of similar coverage pursuant to other law, such as the
bonding requirement at ERISA Section 412. If the waiver request is based on the
existence of alternative coverage, the Applicant must describe such alternative
coverage and enclose proof of the existence of such coverage.
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F. Additional Information
A Direct Contract MAO Applicant must furnish the following financial information
to CMS to the extent applicable:
1. Self-Insurance/Self Funding- If the Direct Contract MAO Applicant’s PFFS
Plan(s) will be self-insured or self-funded, it must forward proof of stop-loss
coverage (if any) through copies of policy declarations.
2. Trust- If the Direct Contract MAO Applicant maintains one or more trusts with
respect to its health plan(s), a copy of the trust documents, and if the trust is
intended to meet the requirements of Section 501(c)(9) of the Internal Revenue
Code, the most recent IRS approval letter.
3. Forms 5500 and M-1- The two most recent annual reports on Forms 5500 and
M-1 (to the extent applicable) for the Direct Contract MAO Applicant’s health
plans that cover prescription drugs for individuals who are Part D eligible.
4. ERISA Section 411(a) Attestation- The Direct Contract MAO (including a
Direct Contract MAO that is exempt from ERISA) must provide a signed
attestation that no person serves as a fiduciary, administrator, trustee, custodian,
counsel, agent, employee, consultant, adviser or in any capacity that involves
decision-making authority, custody, or control of the assets or property of any
employee benefit plan sponsored by the Direct Contract MAO Applicant, if he
or she has been convicted of, or has been imprisoned as a result of his or her
conviction, of one of the felonies set forth in ERISA Section 411(a), for 13
years after such conviction or imprisonment (whichever is later).
5. Defined Benefit Pension Plan- If the Direct Contract MAO Applicant sponsors
one or more defined benefit pension plans (within the meaning of ERISA
Section 3(35)) that is subject to the requirements of Title IV of ERISA, the
latest actuarial report for each such plan.
6. Multi-Employer Pension Plan- If the Direct Contract MAO Applicant is a
contributing employer with respect to one or more multi-employer pension
plans within the meaning of ERISA Section 3(37), the latest estimate of
contingent withdrawal liability.
7. Tax-Exempt Direct Contract MAOs (Only)- a copy of the most recent IRS
tax-exemption.
IV.
INSOLVENCY REQUIREMENTS
A. Hold Harmless and Continuation of Coverage/Benefits.
The Direct Contract MAO shall be subject to the same hold harmless and
continuation of coverage/benefit requirements as other MA contractors.
B. Deposit Requirements - Deposit at the Time of Application
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A Direct Contract MAO generally must forward confirmation of its
establishment and maintenance of a deposit of at least $1.0 Million to be held in
accordance with CMS requirements by a qualified U.S. financial institution. A
“qualified financial institution” means an institution that:
1. Is organized or (in the case of a U.S. office of a foreign banking
organization) licensed, under the laws of the United States or any state
thereof; and
2. Is regulated, supervised, and examined by the U.S. Federal or state
authorities having regulatory authority over banks and trust companies.
The purpose of this deposit is to help ensure continuation of services, protect the
interest of Medicare enrollees, and pay costs associated with any receivership or
liquidation. The deposit may be used to satisfy the minimum net worth
requirement set forth in Section III above.
A Direct Contract MAO may request a waiver in writing of this requirement.
Note: In addition to the requirements in this appendix, if the Direct
Contract MAO is also applying to offer a Direct Contract MA Plan that
provides Part D coverage (i.e., MA-PD), it must complete and submit the
corresponding Direct Contract MA-PD application within this appendix
and meet the Part D Deposit requirements stated in the separate Direct
Contract MA-PD application.
Deposit On and After Effective Date of Contract
Based on the most recent financial statements filed with CMS, CMS will
determine the adequacy of the deposit under this Section and inform the Direct
Contract MAO as to the necessity for any increased deposit. Factors CMS will
consider shall include the total amount of health care expenditures during the
applicable period, the amount of expenditures that are uncovered, and the length
of time necessary to pay claims.
Rules Concerning Deposit
1. The deposit must be held in trust and restricted for CMS’ use in the event of
insolvency to pay related costs and/or to help ensure continuation of services.
2. All income from the deposit are considered assets of the Direct Contract MAO
and may be withdrawn from the deposit upon CMS’ approval. Such approval
is not to be withheld unreasonably.
3. On prior written approval from CMS, a Direct Contract MAO that has made a
deposit under this Section may withdraw such deposit or any part thereof if:
(a) a substitute deposit of cash or securities of equal amount and value is
made;
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(b) the fair market value of the assets held in trust exceeds the required
amount for the deposit; or
(c) the required deposit is reduced or eliminated.
V.
GUARANTEES (only applies to an Applicant that utilizes a Guarantor)
A. General policy
The Direct Contract PFFS MAO, or the legal entity of which the Direct Contract
PFFS MAO is a component, may apply to CMS to use the financial resources of a
Guarantor for the purpose of meeting the requirements of a Direct Contract MAO
set forth above. CMS has the sole discretion to approve or deny the use of a
Guarantor.
B. Request to Use a Guarantor
To apply to use the financial resources of a Guarantor, a Direct Contract MAO must
submit to CMS:
1.
Documentation that the Guarantor meets the requirements for a Guarantor
under paragraph (C) of this section; and
2.
The Guarantor's independently audited financial statements for the current
year-to-date and for the two most recent fiscal years. The financial statements
must include the Guarantor's balance sheets, profit and loss statements, and
cash flow statements.
C. Requirements for Guarantor
To serve as a Guarantor, an organization must meet the following requirements:
1. Be a legal entity authorized to conduct business within a state of the United
States.
2. Not be under Federal or state bankruptcy or rehabilitation proceedings.
3. Have a net worth (not including other guarantees, intangibles and restricted
reserves) equal to three times the amount of the Direct Contract PFFS MAO
guarantee.
4. If a state insurance commissioner or other state official with authority for riskbearing entities regulates the Guarantor, it must meet the net worth requirement
in Section III above with all guarantees and all investments in and loans to
organizations covered by guarantees excluded from its assets.
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5. If the Guarantor is not regulated by a state insurance commissioner or other
similar state official, it must meet the net worth requirement in Section III above
with all guarantees and all investments in and loans to organizations covered by
a guarantee and to related parties (subsidiaries and affiliates) excluded from its
assets.
D. Guarantee Document
If the guarantee request is approved, a Direct Contract MAO must submit to CMS a
written guarantee document signed by an appropriate Guarantor. The guarantee
document must:
1. State the financial obligation covered by the guarantee;
2. Agree to:
(a) Unconditionally fulfill the financial obligation covered by the guarantee;
and
(b) Not subordinate the guarantee to any other claim on the resources of the
Guarantor;
3. Declare that the Guarantor must act on a timely basis, in any case not more
than five business days, to satisfy the financial obligation covered by the
guarantee; and
4. Meet any other conditions as CMS may establish from time to time.
E. Ongoing Guarantee Reporting Requirements
A Direct Contract MAO must submit to CMS the current internal financial
statements and annual audited financial statements of the Guarantor according to
the schedule, manner, and form that CMS requires.
F. Modification, Substitution, and Termination of a Guarantee
A Direct Contract MAO cannot modify, substitute or terminate a guarantee unless
the Direct Contract MAO:
1. Requests CMS' approval at least 90 days before the proposed effective date of
the modification, substitution, or termination;
2. Demonstrates to CMS' satisfaction that the modification, substitution, or
termination will not result in insolvency of the Direct Contract MAO; and
3. Demonstrates how the Direct Contract MAO will meet the requirements of
this Section.
G. Nullification
If at any time the Guarantor or the guarantee ceases to meet the requirements of
this section, CMS will notify the Direct Contract MAO that it ceases to recognize
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the guarantee document. In the event of this nullification, a Direct Contract MAO
must:
1. Meet the applicable requirements of this section within 15 business days; and
2. If required by CMS, meet a portion of the applicable requirements in less than
the 15 business days in paragraph (G.1.) of this section.
VI. ONGOING FINANCIAL SOLVENCY/CAPITAL ADEQUACY REPORTING
REQUIREMENTS
An approved Direct Contract MAO is required to update the financial information set
forth in Sections III and IV above to CMS on an ongoing basis. The schedule,
manner, form and type of reporting, will be in accordance with CMS requirements.
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8 APPENDIX IV: Medicare Cost Plan Service Area
Expansion Application
8.1
State Licensure
To ensure that all Cost Plan contractors operate in compliance with state and federal
regulations, CMS requires Cost Plan contractors to be licensed under state law. This will
ensure that Cost Plan contractors adhere to state regulations aimed at protecting Medicare
beneficiaries. The following attestations were developed based on regulations at 42 CFR
417.404.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: STATE LICENSURE
YES
NO
1. Applicant is licensed under State law as a riskbearing entity eligible to offer health insurance or
health benefits coverage in each State in which
the Applicant proposes to offer the managed care
product. In addition, the scope of the license or
authority allows the Applicant to offer the type of
managed care product that it intends to offer in
the state or states.
•
If “Yes”, upload in HPMS an executed
copy of a state licensing certificate and the
CMS State Certification Form for each
state being requested.
•
Note: Applicant must meet and document
all applicable licensure and certification
requirements no later than the Applicant’s
final upload opportunity, which is in
response to CMS’ NOID communication.
2. Applicant is currently under some type of
supervision, corrective action plan or special
monitoring by the State licensing authority in any
State. This means that the Applicant has to
disclose actions in any state against the legal
entity which filed the application.
•
If “Yes”, upload in HPMS an explanation
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N/A
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE
FOLLOWING STATEMENTS: STATE LICENSURE
YES
NO
N/A
of the specific actions taken by the State
licensing authority.
3. Applicant conducts business as "doing business
as" (d/b/a) or uses a name different than the name
shown on its Articles of Incorporation.
•
If “Yes”, upload in HPMS a copy of the
state approval for the d/b/a.
4. For states or territories whose license(s) renew
after the first Monday in June, Applicant agrees
to submit the new license promptly upon
issuance. Applicant must upload into HPMS no
later than the final upload opportunity a copy of
its completed license renewal application or other
documentation that the State’s renewal process
has been followed (e.g., invoice from payment of
renewal fee) to document that the renewal process
is being completed in a timely manner.
•
Note: If the Applicant does not have a
license that renews after the first Monday
in June, then the Applicant should respond
"N/A".
5. Applicant has marketing representatives and/or
agents who are licensed or regulated by the State
in which the proposed service area is located.
• If the State in which the proposed service
area is located doesn’t require marketing
representatives/agents to be licensed,
Applicant should respond “N/A”.
B. In HPMS, upload an executed copy of the State Licensing Certificate and the CMS
State Certification Form for each state being requested, if Applicant answers “Yes” to
the corresponding question above.
C. In HPMS, upload the State Corrective Plans / State Monitoring Explanation (as
applicable), if Applicant answers “Yes” to the corresponding question above.
D. In HPMS, upload the State Approval for d/b/a, if Applicant answers “Yes” to the
corresponding question above.
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8.2
Service Area
The purpose of the service area attestation is to clearly define which areas will be served
by the MAO. A service area for local plans is defined as a geographic area composed of a
county or multiple counties, while a service area for MA regional plans is a region
approved by CMS. The following attestation was developed to implement the regulations
of 42 CFR 422.2.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: SERVICE AREA
YES
NO
1. Applicant meets the county integrity rule as outlined in
Chapter 4 of the MMCM and will serve the entire county.
•
If "No", upload in HPMS a justification for wanting to
serve a partial county.
B. In HPMS, on the Contract Management/Contract Service Area/Service Area Data
page, enter the state and county information for the area the Applicant proposes to
serve. Applicant must also upload a justification for wanting to serve a partial county,
if Applicant answered “No” to question 1 above.
8.3
CMS Provider Participation Contracts & Agreements
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: PROVIDER CONTRACTS AND
AGREEMENTS
YES
1. Applicant has executed provider, facility, and supplier
contracts in place to demonstrate adequate access and
availability of covered services throughout the requested
service area.
2. Applicant agrees to have all provider contracts and/or
agreements available upon request and onsite.
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NO
B. In HPMS, upload a template copy of each first tier provider contract(s) and/or
agreement(s) between the Applicant and its health care contractors (i.e., direct
contracts with physicians, medical groups, IPAs, PHOs, hospitals, skilled nursing
facilities, etc.).
C. In HPMS, upload a template copy of each downstream subcontract that may exist
between a Medical group(s), IPA(s), PHO(s), etc. and its downstream providers
(e.g., 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 in addition
to the contract between the Applicant and the IPA referenced in section B above).
D. In HPMS, upload a completed “CMS Provider Contract Template Matrix”, which is
a crosswalk to show where in each provider contract/agreement template the
referenced CMS regulations are included. Applicant should list each contracted
(including sub-contracted) provider template on the matrix.
E.
In HPMS, upon request, upload a completed “Contract Signature Page Matrix”,
which is a document that must accompany the sample of contract signature pages
that CMS will request during the application review process. This document is not
required for application submission.
F.
Note: As part of the application review process, Applicants will need to provide
signature pages for physician and provider contracts that the CMS reviewers select
based upon the CMS Provider and Facility tables that are a part of the initial
application submission. CMS reviewers will include a list of providers and specific
instructions in the CMS’ first deficiency letter.
G. In HPMS, upload a completed “Contract and Signature Index-Providers”, which is
an index to link contracted primary care and specialty physicians listed in the MA
Provider Table to the template contract(s) listed in the CMS Provider Contract
Template and indicate which contract(s) execute the relationship between the
applicant and the provider. For MA applicants requesting an SAE, the index will
also serve to document whether any of the applicant’s current providers will be part
of the network available in the expansion area.
H. In HPMS, upload a completed “Contract and Signature Index-Facilities”, which is an
index to link contracted ancillary or hospital providers listed in the MA Facility
Table to the template contract(s) listed in the CMS Template Provider Contract
Matrix and indicate which contract(s) execute the official relationship between the
applicant and the provider. For MA applicants requesting an SAE, the index will
also serve to document whether any of the applicant’s current providers will be part
of the network relied upon in the expansion area/network.
I.
In HPMS, upload a completed “MA Signature Authority Grid”, which is a grid to
document whether physicians/practitioners of a contracted provider group are
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employees of the medical practice or under an alternate arrangement (e.g., medical
practice partnership) through which another individual can sign on the provider’s
behalf. The grid should display the medical group, the person authorized to sign
contracts on behalf of the group, and the roster of employed/partner
physicians/practitioners of that group.
8.4
Contracts for Administrative & Management Services
This section describes the requirements the Applicant must demonstrate to ensure any
contracts for administrative/management services comply with the requirements of all
Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 417.412.
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: CONTRACTS FOR ADMINISTRATIVE
MANAGEMENT SERVICES
YES
1. Applicant has contracts with related entities, contractors and
subcontractors (first tier, downstream, and related entities) to
perform, implement or operate any aspect of the Cost Plan
operations.
2. Applicant has administrative/management contract/agreement
with a delegated entity to manage/handle all staffing needs
with regards to the operation of all or a portion of the Cost
Plan.
3. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
portion of the systems or information technology to operate
the Cost Plan.
4. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
portion of the claims administration, processing and/or
adjudication functions.
5. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
portion of the enrollment, disenrollment and membership
functions.
6. Applicant has an administrative/management
contract/agreement with a delegated entity to perform any
and/or all marketing including delegated sales broker and
agent functions.
7. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
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NO
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING
STATEMENTS: CONTRACTS FOR ADMINISTRATIVE
MANAGEMENT SERVICES
YES
NO
portion of the credentialing functions.
8. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
portion of call center operations.
9. Applicant has an administrative/management
contract/agreement with a delegated entity to perform all or a
portion of the financial services.
10. Applicant has an administrative/management
contract/agreement with a delegated entity to delegate all or a
portion of other services that are not listed.
11. Applicant agrees that as it implements, acquires, or upgrades
health information technology (HIT) systems, where
available, the HIT systems and products will meet standards
and implementation specifications adopted under section
3004 of the Public Health Services Act as added by section
13101 of the American Recovery and Reinvestment Act of
2009, P.L. 111-5.
B. In HPMS, complete the Delegated Business Function Table under the Part C Data
Link.
Note: If the Applicant plans to delegate a specific function but cannot at this time
name the entity with which the Applicant will contract, enter "Not Yet Determined"
so that CMS is aware of the Applicant’s plans to delegate that function. If the
Applicant delegates a particular function to a number of different entities (e.g., claims
processing to multiple medical groups), then list the five most significant entities for
each delegated business function identified and in the list for the sixth, enter
"Multiple Additional Entities".
C. In HPMS, upload executed management contracts or letters of agreement for each
contractor or subcontractor (first tier, downstream, and related entities).
8.5
Health Services Management & Delivery
The purpose of the Health Service Management and Delivery attestations is to ensure that
all Applicants deliver timely and accessible health services for Medicare beneficiaries.
CMS recognizes the importance of ensuring continuity of care and developing policies
for medical necessity determinations. In efforts to accomplish this, Cost Plan contractors
will be required to select, evaluate, and credential providers that meet CMS’ standards, in
addition, to ensuring the availability of a range of providers necessary to meet the health
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care needs of Medicare beneficiaries. The following attestations were developed to
implement the regulations of 42 CFR 417.414, 417.416.
A. In HPMS, upload the following completed HSD tables:
8.6
MA Provider Table
MA Facility Table
Part C Application Certification
A. The Applicant does not need to complete attestations for the Part C Application
Certification Form. The Applicant must follow instructions in sub-section B
below.
B. In HPMS, upload a completed and signed Adobe.pdf format copy of the Part C
Application Certification Form.
Note: Once the Part C application is complete, Applicants seeking to offer a Part D plan
must complete the Part D application in HPMS. PFFS and Cost Plan SAE organizations
have the option to offer Part D plans. MSAs are not allowed to offer Part D plans.
8.7
Full Financial Risk
A. In HPMS, upload a description of any risk sharing with providers and provide
physician incentive plans (PIP) disclosure for the new providers in the expanded
areas.
8.8
Budget Forecast
A. In HPMS, upload a copy of the Cost Budget for the expanded service area.
Note: The cost budget must be based on the Cost plan financial and statistical records that
can be verified by qualified auditors. The cost data must be based on an approved method
of cost finding and on the accrual method of accounting.
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| File Type | application/pdf |
| File Title | PART 1 GENERAL INFORMATION |
| Author | Emmanuelle Goodrich |
| File Modified | 2012-09-17 |
| File Created | 2012-09-17 |