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pdfSummary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
1. Edits to entire document including the
addition of missing words, clarifying
language, capitalization, deletion of missing
spaces, and final dates.
Purpose of the Revision/Clarification
2014 Part C
Application
TECHNICAL CHANGES
To maintain a consistent format and
Entire
provide accurate timeframes and
Document
instructions.
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
All Sections
N/A
N
3.1
60-day
I
SUBSTANTIVE CHANGES
2.
Added attestation #3 to section 3.1 of
application:
“The Applicant attests that it has at least 5,000
individuals (or 1,500 individuals if the
organization is a PSO) enrolled for the
purpose of receiving health benefits from the
organization; or it has at least 1,500
individuals (or 500 individuals if the
organization is a PSO) enrolled for purposes
of receiving health benefits from the
organization and the organization primarily
serves individuals residing outside of
We are proposing to apply the
minimum enrollment requirement to
new applications in an effort to
strengthen our ability to distinguish
stronger applicants for Part C
Program Participation. Pursuant to
42 CFR 422.514 and 423.512, an
organization must meet minimum
enrollment requirements in order to
hold a Medicare Advantage contract
with CMS. As stated in our June 26,
1998 Interim Final Rule with
1
Section 3 Attestations
Experience &
Organization
History
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
urbanized areas as defined in §412.62(f) (or,
in the case of a PSO, the PSO meets the
requirements in §422.352(c)).”
Comment, the minimum enrollment
requirement is an indicator that the
organization applying for a Medicare
Advantage contract is able to handle
risk and capitated payments. In that
rule, we also stated our expectation
that an organization is able to
effectively manage a health care
delivery system including the
enrollment and disenrollment of
members and the timely payment of
claims, provide quality assurances,
and have systems to handle
grievances and appeals. Recognizing
that some new organizations with no
prior enrollment may apply for a
contract, the regulation also provides
for a transition period allowing CMS
to waive the minimum enrollment
requirement during an organization’s
2
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
first three years of operation.
CMS permits organizations that
initially fail to meet the minimum
enrollment requirements to continue
operating their Medicare Advantage
contracts beyond the transition period
as long as they are in compliance
with other stipulated contractual
requirements. CMS has seen an
increase in plans that have
operational difficulties, which often
results in disruption of benefits or
services provided to beneficiaries.
We are proposing that, starting with
the contract year 2015 application
cycle, applicants applying for either
an initial contract or a service area
expansion of an existing contract
submit minimum enrollment
3
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
information as specified in §§
422.514 of this part. An applicant
that does not meet the minimum
enrollment requirement may request
a waiver of this requirement. CMS
may consider this information in the
determining whether to approve the
application request. In so doing, we
believe that this will help to reduce
the chances of plan failure and limit
beneficiary disruption of benefits and
services related to plan failure.
3. Removed reference to Partial County
Network Assessment Table.
Extending the HPMS automated
network review to partial counties
eliminates the need for the Partial
County Network Assessment Table,
which assisted the reviewer with
manual review.
4
Section 3 Attestations
30 day
3.8 Service Area
D
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
4. Referenced the CMS Medicare Advantage
Contract Amendment released in HPMS on
10/5/12.
CMS encourages applicants (and
current contractors) to use the CMSdeveloped MA contract amendment
by referencing the document here in
the Provider Contracting section of
the application.
CMS encourages applicants (and
current contractors) to use the CMSdeveloped MA contract amendment
by referencing the document here in
the Administrative Contracting
section of the application.
We are no longer asking the applicant
to name the contracted facility at
which each contracted specialist has
admitting privileges on the Provider
Table. Instead, we are asking the
applicant to attest to the fact that
contracting specialists have admitting
privileges at contracted facilities.
5. Referenced the CMS Medicare Advantage
Contract Amendment released in HPMS on
10/5/12.
6. Added new attestation related to admitting
privileges of contracted providers at
contracted facilities.
5
2014 Part C
Application
Section 3 –
Attestations
Section 3 –
Attestations
Section 3 –
Attestations
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
30 day
N
3.9 CMS Provider
Participation
Contracts &
Agreements
30 day
N
30 day
I
3.10 Contracts for
Administrative &
Management
Services
3.11 Health
Services
Management &
Delivery
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
7. Added new Transplant Attestation.
8. Added the instruction for the applicant to
enter the National Association of Insurance
Commissioners (NAIC) number if there is
one to the CMS State Certification Request
form.
9. Added language clarifying that partial
county network assessments are automated
and the applicant must follow the Exception
Request process that is available to fullcounty applicants.
10. Removed Section IV of Partial County
Justification referring to Provider Network
Assessment for partial counties.
Purpose of the Revision/Clarification
2014 Part C
Application
Adding new attestation pertaining to
delivery of transplant services
according to CMS guidelines in place
of network review of transplant
facility information on Facility Table.
CMS needs to collect the
organizations NAIC number to help
expedite its financial review of the
application.
Section 3 –
Attestations
Clarification of new process.
Section 4 –
Document
Upload
Templates
This section no longer applies due to
the HPMS automated review of
partial county networks.
6
Section 4 –
Document
upload
templates
Section 4 –
Document
Upload
Templates
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
30 day
I
3.11 Health
Services
Management &
Delivery
60-day
I
4.2 CMS State
Certification Form
30 day
N
30 day
D
4.13 Partial County
Justification
4.13 Partial County
Justification
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
11. Removed Section 4.14 Partial County
Network Assessment Table.
Purpose of the Revision/Clarification
This section no longer applies due to
the HPMS automated review of
partial county networks.
2014 Part C
Application
Section 4 –
Document
Upload
Templates
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
4.13 Partial County 30 day
D
Justification
HSD INSTRUCTIONS, TABLES AND EXCEPTION PROCESS
1. Edits to HSD Instructions document
included adding clarifying language to the
MA Provider table, MA Facility table and
Appendix C sections.
2. For the MA Facility Table changed Column
D from Medicare Certification Number
(MCN) to CMS Certification Number.
Instructions were unclear in the HSD
instructions document.
N/A
N/A
60-day
N
The CCN verifies the facility is
Medicare certified and for what type
of service. The CCN for facilities
have 6 digits. The first 2 digits
identify the State in which the
provider is located. The last 4 digits
identify the type of facility.
3. MA Provider Table - Removed column (L)
Removing these columns because we
“Contracted Hospital Where Privileged” and are replacing with attestation
(M) Hospital National Provider Identifier
regarding privileges at contracting
N/A
N/A
60-day
N
N/A
N/A
30-day
D
7
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Number.
4. HSD Instructions, MA Provider Table
Instructions (pg 4)- Emphasized existing
guidance and added clarifying language
about not listing providers that don’t
provide reasonable access to beneficiaries.
5. HSD Instructions, MA Provider Table
Instructions (pg 4)- Clarified some of the
requirements for the providers listed on the
table.
6. HSD Instructions, MA Provider Table
Instructions (pg4) – Emphasized existing
and added new language regarding applicant
responsibility for ensuring listed providers
meet licensing and credentialing
requirements for listed specialties.
7. HSD Instructions, MA Provider Table
Instructions (pg 6) – Deleted columns L and
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
facilities.
On the HSD provider table, some
applicants continue to list thousands
of extra, unnecessary providers that
do not affect their network scores and
inappropriately extend the HPMS
report processing time.
This will eliminate the practice of
applicants listing inappropriate
providers on the Table.
N/A
N/A
30-day
N
N/A
N/A
30-day
N
Purpose is to ensure that applicants
do not list inappropriate and
unqualified providers on their
Provider Tables.
N/A
N/A
30-day
N
Replacing with attestation.
N/A
N/A
30-day
D
8
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
M pertaining to Contracted Hospital Where
Privileged.
8. HSD Instructions, MA Facility Table
Instructions (pg 7) – Emphasized existing
guidance and added clarifying language
about not listing facilities that don’t provide
reasonable access to beneficiaries.
9. HSD Instructions, Requesting Exceptions
(pg9) – Added note that partial county
applicants should use the Exception process
beginning with CY2015 applications.
10. HSD Instructions, Appendix A – CY2015
HSD Submission Frequently Asked
Questions – Amended response to #11 (pg
13) to clarify that applicants should only
enter “000” for providers that are alternate
providers submitted as part of an exception
request.
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
On the HSD facility table, some
applicants continue to list thousands
of extra, unnecessary providers that
do not affect their network scores and
inappropriately extend the HPMS
report processing time.
Updating instructions to reflect
automated network review for partial
counties.
N/A
N/A
30-day
D
N/A
N/A
30-day
N
Clarification of instructions.
N/A
N/A
30-day
N
9
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
11. Appendix C – Field Edits for the MA
Provider and Facility Tables – (pg21)
Removed edits for Contracted Hospital
Where Privileged.
12. Appendix C – Field Edits for the MA
Provider and Facility Tables – (pg22)
removed the CCN reference to 049 Physical
Therapy.
13. Exception Request Template Q1 – added
language to clarify instructions regarding
listing individual physicians rather than
provider groups.
14. Exception Request Template Q2 – added
language to clarify how to use medicare.gov
to search for available providers.
15. Exception Request Template Q5 – added
language to clarify how to report
time/distance between available contracted
providers and deficient zip codes/cities.
Purpose of the Revision/Clarification
2014 Part C
Application
Matches other changes to application. N/A
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
N/A
30-day
D
Physical Therapy facilities do not
have CCNs.
N/A
N/A
30-day
D
Clarification of instructions.
N/A
N/A
30-day
N
Clarification of expectations.
N/A
N/A
30-day
N
Clarification of instructions.
N/A
N/A
30-day
I
10
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
2014 Part C
Application
16. Exception Request Template pg 2 – changed Clarification of instructions.
instructions to clarify how to report on
time/distance between the available
contracted providers and deficient zip
codes/cities.
APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposal
N/A
1. Removed the D-SNP State Medicaid
Agency Contract Negotiation Status
Document as an upload requirement.
The D-SNP State Medicaid Agency
Contract Negotiation Status
Document is no longer required for
the application process. For CY 2013
this document was not reviewed.
2. Removed attestation #6, “Provide the State
Medicaid contract begin date, under the DSNP State Medicaid Agency Contracts
Attestation section.”
To be consistent with the electronic
application which does not require
this information.
APPENDIX I:
Solicitations
for Special
Needs Plan
(SNP)
Proposals
APPENDIX I:
Solicitations
for Special
Needs Plan
(SNP)
Proposals
11
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
N/A
30 –day
I
Former #14
60-day
D
6. – D-SNP State
Medicaid Agency
Contract area
attestation
60-day
D
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
3. Removed attestation #7, “Provide the State
Medicaid contract end date, under the DSNP State Medicaid Agency Contracts
Attestation section.”
Purpose of the Revision/Clarification
To be consistent with the electronic
application which does not require
this information.
2014 Part C
Application
APPENDIX I:
Solicitations
for Special
Needs Plan
(SNP)
Proposals
4. Removed attestation #8, “Does the applicant This is a redundant attestation for this APPENDIX I:
want the State Medicaid Agency Contract to section of the SNP proposal. It was
Solicitations
be reviewed to determine if it qualifies as a
similar to Attestation #2 which says,
for Special
FIDE SNP for the contract period(s)
“Applicant wishes the contract with
Needs Plan
identified in numbers 6 and 7.”
the State Medicaid Agency(ies) to be (SNP)
reviewed to determine if it qualifies
Proposals
as a fully integrated dual eligible
SNP (FIDE).”
5. Deleted approximately 240 Model of Care
This information duplicates
APPENDIX I:
attestation questions from application. One information collected in another
Solicitations
attestation and 2 uploads remain under
document, the Model of Care (OMB for Special
Model of Care. The attestation remaining is control number 0938-0936).
Needs Plan
“Applicant has submitted a written
(SNP)
description of its Model of Care as defined
Proposals
12
Level of
Applicant
Burden
I=
Increases
Category of
Application Section
burden
Comment
D–
Decreases
burden
N – No
Change
6. – D-SNP State
60-day
D
Medicaid Agency
Contract area
attestation
6. – D-SNP State
Medicaid Agency
Contract area
attestation
60-day
D
11. Model of Care
Attestations
60 day
D
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
in the Model of Care Matrix upload
document.”
6. Revisions to the CY2015 Model of Care
Matrix Upload Document.
7. Replaced 2014 D-SNP State Medicaid
Agency Contract Matrix with 2015 D-SNP
State Medicaid Agency Contract Matrix.
8. Replaced 2014 Fully Integrated Dual
Eligible (FIDE) Special Needs Plan (SNP)
Contract Review Matrix with 2015 Fully
Integrated Dual Eligible (FIDE) Special
CMS revised CY2015 Model of Care
Matrix Upload Document to clarify
and accept comments received from
60 day comments period.
APPENDIX I:
Solicitations
for Special
Needs Plan
(SNP)
Proposals
Updated D-SNP State Medicaid
APPENDIX I:
Agency Contract matrix in
Solicitations
application to reflect the CY2015 D- for Special
SNP State Medicaid Agency Contract Needs Plan
matrix changes.
(SNP)
Proposals
Updated the Fully Integrated Dual
APPENDIX I:
Eligible (FIDE) Special Needs Plan
Solicitations
(SNP) Contract Review matrix in
for Special
application to reflect the CY2015
Needs Plan
13
18. Model of Care
Matrix Upload
Document
30 day
N
14. D-SNP State
Medicaid Agency
Contract Matrix
30 day
N
15. Fully
Integrated Dual
Eligible (FIDE)
Special Needs Plan
30 day
N
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Needs Plan (SNP) Contract Review Matrix.
9. Replaced 2014 I-SNP Upload Documents
with 2015 I-SNP Upload Documents.
10. Deleted I-SNP attestation upload document.
11. Replaced 2014 ESRD Waiver Request
Upload Document version with 2015 ESRD
Waiver Request Upload Document.
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
Fully Integrated Dual Eligible (FIDE) (SNP)
Special Needs Plan (SNP) Contract
Proposals
Review matrix changes.
(SNP) Contract
Review Matrix
Updated the I-SNP Upload
Documents in application to reflect
the CY2015 I-SNP Upload
Documents changes.
Inserted the attestation that was in the APPENDIX I:
I-SNP attestation upload document
Solicitations
within the I-SNP upload documents.
for Special
Needs Plan
(SNP)
Proposals
Updated the ESRD Waiver Request
APPENDIX I:
Upload Document in application to
Solicitations
reflect the CY2015 ESRD Waiver
for Special
Request Upload Document changes.
Needs Plan
(SNP)
Proposals
16. I-SNP Upload
Documents
30 day
N
Former #18
30 day
N
17. ESRD Waiver
Request Upload
Document
30 day
N
14
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
2014 Part C
Application
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
8.2 Service Area
30 day
D
8.5 Health Services
Management &
Delivery
30 day
D
8.5 Health Services
Management &
Delivery
30 day
I
APPENDIX IV: Medicare Cost Plan Service Area Expansion Application
1. Removed reference to Partial County
Network Assessment Table.
2. Added new attestation related to admitting
privileges of contracted providers at
contracted facilities.
3. Added new Transplant Attestation.
This section no longer applies due to
the HPMS automated review of
partial county networks.
APPENDIX
IV: Medicare
Cost Plan
Service Area
Expansion
Application
We are no longer asking the applicant APPENDIX
to name the contracted facility at
IV: Medicare
which each contracted specialist has
Cost Plan
admitting privileges on the Provider
Service Area
Table. Instead, we are asking the
Expansion
applicant to attest to the fact that
Application
contracting specialists have admitting
privileges at contracted facilities.
Adding new attestation pertaining to
APPENDIX
delivery of transplant services
IV: Medicare
according to CMS guidelines in place Cost Plan
of network review of transplant
Service Area
15
Summary of Substantive and Technical Changes for
All Part C Application Revisions from 2014 Version of Part C Application to 2015 Version
30 day PRA Package
Revision/Clarification
Purpose of the Revision/Clarification
2014 Part C
Application
facility information on Facility Table. Expansion
Application
16
Application Section
Level of
Applicant
Burden
I=
Increases
Category of
burden
Comment
D–
Decreases
burden
N – No
Change
| File Type | application/pdf |
| File Title | Revision |
| Author | CMS |
| File Modified | 2013-10-30 |
| File Created | 2013-10-30 |