Response to Comments

2016 Part C MA & Cost Plan Application - 60 Day
Comment
Number

1

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

Application
Section

Page
number

Description of the Issue or
Question

United Health
Plan



3.5

27

In section 2.3 letter B, please
confirm reference to Chapter 11
of the MMCM is a typo and
should reference Chapter 21 of
the MMCM
App Excerpt:
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
(MMCM) are implemented and
specific to the issues and
challenges presented by the Part
C program.

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)
In section 2.3 letter B, please
confirm reference to Chapter 11
of the MMCM is a typo and
should reference Chapter 21 of
the MMCM

Revision

Accept : Section 50.1-50.7.7
of chapter 21 of the MMCM
discusses the elements of an
effective compliance plan.
CMS will correct the
application to reference
Chapter 21 instead of Chapter
11.

Comment
Number

2

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

United Health
Plan



Application
Section

Page
number

Description of the Issue or
Question

3.16 attestation
3

41

Applicant agrees to give
beneficiary prompt notice of
acceptance or denial of a claim’s
payment in a format consistent
with the appeals and notices
requirements stated in 42 CFR
Part 422 Subpart M.

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)
CMS rules do not require that
plans provide notice of claim
acceptance when there is no cost
share involved (except for PFFS
claims). There is also no
requirement to notify
beneficiaries of claim denials
when the claim only involves
provider reimbursement (such
notices would be confusing to
beneficiaries). Rather, the
requirement is that when a claim
is denied resulting in member
liability, plans must provide the
member with his or her appeals
rights. We suggest an addition
to the attestation that explains
that the notice is required in all
cases where there is cost-sharing
or member liability. We request
that the attestation be revised as
follows: Applicant agrees to give
beneficiary prompt notice of
acceptance or denial of a claim's
payment in a format consistent
with the appeals and notice
requirements stated in 42 CFR
Part 422 Subpart M, in all cases
where there is a member costsharing or member liability.

Revision

Reject: The change the
commenter requested was not
a part of the the 2016
application package and this
language has already been
approved by OMB.

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

3

United Health
Plan

4

Untied Health
Plan

Comment
Number

Application
Section

Page
number



State
certification
form

62



N/A

N/A

Description of the Issue or
Question

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)

We recommend CMS amend the We recommend CMS amend the
state certification form to delete state certification form to delete
question 3.
question 3. Specifically, the
nomenclature creates confusion
for states that use different
terminology for benefit plans.
For example, a state may use the
terms “closed panel” to describe
products, rather than the term
“HMO.” From a state’s
perspective, an HMO is typically
a type of entity license. The
certification form is effective
without the question in that the
state’s obligation is to certify
that the applying entity is
licensed and solvent.
Alternatively, regulatory changes
could be made to describe the
products more broadly to
improve the alignment with the
terminology used by the states.
We would welcome the
opportunity to work with CMS
on this issue and provide
additional examples.

Revision

Reject: States have been able
to answer this question
without difficulty. The
question refers to the type of
application filed with CMS
and not what definition the
state uses. Moreover, states
are able to contact CMS if
they are unaware of the type
of application filed.

The CMS downloadable certified
Transplant facilities list is in
PDF format requiring
considerable manual
manipulation to convert to Excel
or Access so that it can be used
in automated reporting.

Insertion

Reject: CMS provides this in
PDF format.

We respectfully request that
CMS produce the certified
transplant list in a .txt or
Excel/Access, similar to the
other website posted
downloadable files of CMS
certified providers (Hospital,
Home Health, DME, etc.)

Comment
Number

5

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

United Health
Plan



Application
Section

Page
number

Description of the Issue or
Question

Exceptions
Request
Template

N/A

It is redundant/duplicative to
require health plans to repeat
listing the contracted
providers/facilities "that will
ensure access" on the Exception
form when they are already
listed on the HSD table: LIST
THE CONTRACTED
PROVIDERS/FACILITIES THAT
WILL ENSURE ACCESS (THEY
MUST BE LISTED IN THE HSD
TABLE UNDER THE COUNTY IN
WHICH THEY ARE PROVIDING
SERVICES). ALSO, LIST THE
CLOSEST CONTRACTED
PROVIDER/FACILITY OF THE
SPECIALTY CODE TYPE.

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)
It is suggested that the Exception
form read: LIST THE
CLOSEST CONTRACTED
PROVIDER/FACILITY OF
THE SPECIALTY CODE
TYPE.

Revision

Reject: The exception
template list of contracted
providers/facilities requests
specific information to
identify, the name, address,
time and distance of next
closest provider/facility for
each deficient zip code. This
information helps support an
applicant's reasonable access
explanation. The HSD table
does not provide this
information. Exception
requests require applicants to
explain how they will ensure
acceptable access to the
particular provider or facility
for the MA' plan's enrollees.
Applicants completing this
section may realize that there
may be additional noncontracted providers located
closer to the deficient zip
codes than their closest
contracted providers. This
information may help them
meet the distance
requirements.

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

Application
Section

Page
number

Description of the Issue or
Question

6

Untied Health
Plan



N/A

N/A

CMS requires information that is
not readily or easily available for
use in an automated fashion. For
instance, the number of
Medicare certified beds for
hospitals, SNFs, ICUs and IP
Psych facilities is not readily
available to MCOs.

We believe that CMS's
requirements for this data is
administratively burdensome.
We request that CMS provide
certain information
downloadable in excel or other
data files that will assist plans in
their automated production of
HSD tables and population of
these fields with accurate CMS
information. Example, CMS
should provide a resource from
which MCOs can obtain bed
counts, by hospital location, so
that this information is consistent
and available to all health plans.

Insertion

Reject: CMS does not believe
this requirement is
burdensome and applicants
are aware of the process for
providing this information for
its contracted providers.

7

United Health
Plan



N/A

N/A

Medicare.gov lists services
available at an Acute Inpatient
Hospital, yet the hospital
operating certificate may not be
approved by DOH to provide
those services, or the hospital
confirms they do not provide
those services.

Please clarify how to address a
service or provider that is posted
to Medicare.gov as being
Medicare participating and those
providers are used to judge
network adequacy/accessibility,
but plans find out through
provider verification that they do
not perform the services or are
not participating (i.e. cardiac
catherization v. cardiac surgery)?

Insertion

Reject: This comment does
not represent a change to the
Application or HSD Facility
Tables. While CMS
understands that Medicare.gov
is not 100 percent accurate
because of changes in
provider status, if the
applicant finds through direct
contract that the service is not
provided at the facility (or
visa-versa), the applicant
should rely upon the facility's
data rather than the website.
The applicant should
adequately document the
facility's information in case
CMS were to request it.

Comment
Number

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

8

United Health
Plan

9

10

Comment
Number

Application
Section

Page
number

Description of the Issue or
Question



General
Information
Section 1.8

12

Last year, health plans received
final CMS instructions and
forms on January 13, 2014 for a
February 18, 2014 deliverable.
CMS time/distance Criteria
Guidance was received in late
December for a February
deliverable. As a high volume
HSD table submitter, this
timeline is very problematic as
UHC already has its tables
largely built by the time the
updated information is made
available. This then requires that
we go back and re-do work; and
may also require programming
changes that are difficult to
accomplish within that
timeframe.

United Health
Plan



HSD
Instructions
Appendix A

10

United Health
Plan



HSD
Instructions
Appendix A

17-18

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)
We ask that CMS provide
criteria and final
instruction/forms earlier in the
process. Receiving the final
instructions and forms in Nov.
would be optimal.

Insertion

Reject: CMS believes the
current timeline is reasonable
for applicants to submit
required materials by the due
dates.

HSD Pre-Checks are allowed on Since ACCs are automated, we
Thursdays 8PM ET only.
would like to see CMS create an
open window for on demand PreChecks in lieu of date/time
specific limitations. This would
allow table editing work to
remain more fluid and timely.

Revision

Reject: CMS will consider the
comment for Contract Year
2017.

Error Reports contain a limited
number of error data lines,
requiring a fix of those errors
and resubmitting only to learn
there are additional data errors
under the same H#.

Revision

Reject: This comment is not a
part of the 2016 application
package for comment.

We ask that CMS update their
error reporting to include all
errors under an H# in a single
report.

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

11

United Health
Plan

12

United Health
Plan

Comment
Number

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)

Application
Section

Page
number



Provider and
Facility Tables

N/A

Provider & Facility tables each
have a required data element of
"Are you using the CMS
amendment, Y or N?" This is
answered the same for every
provider listed in HSD.

This is already addressed as an
attestation. We feel this is
redundant and should be
removed from the HSD tables.

Deletion

Accepts: CMS maintains the
right to collect contracts for
review. Therefore, CMS does
not believe that deleting this
requirement will significantly
hamper our review.



N/A

N/A

The required data element
"Employment Status" seems
unnecessary, since all
downstream providers are
subject to the terms of our
agreements whether they are
employees or subcontractors.

We recommend that this be
deleted as a data element.

Deletion

Reject: CMS agrees with the
commenter that contracted
and employed providers are
subject to the same
requirements and terms.
However, CMS requests
employment status to assist
reviewers in selecting only
contracted (not employed)
providers. While CMS is no
longer requesting provider
contracts as part of the
standard review, CMS
maintains the right to include
a contract review and would
need to know if the provider
was employed or contracted in
order to select the appropriate
sample.

Description of the Issue or
Question

Comment
Number

13

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

United Health
Plan



Application
Section

Section 3.11
Attestation 7

Page
number

Description of the Issue or
Question

Attestation Statement #7:
Applicant agrees that each of its
contracted physicians/providers
listed in the Provider Table has
admitting privileges (other than
courtesy privileges) at a
contracted facility.
All of the physicians/providers
listed in the Provider Table have
admitting privileges if required
to have admitting privileges.
However, some of the
physician/providers listed in the
provider table, e.g.,
Chiropractor, Podiatry - do not
normally require admitting
privileges or may have
arrangements with another
participating physician to admit
on their behalf. The attestation
of admitting privileges for these
providers is not relevant.

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)
We ask that CMS revise the
attestation regarding admitting
privileges since plans cannot
attest to a provider that is not
required to have admitting
privileges (e.g., chiropractor,
podiatry). For example, the
attestation could read:
Applicant agrees that each of its
contracted physicians/providers
that is required to have admitting
privileges and is listed in the
Provider Table has admitting
privileges (other than courtesy
privileges) at a contracted
facility.

Revision

Reject: CMS has changed this
attestation to state
"applicable"
physicians/providers for
contract year 2016

Comment
Number

Source of
Comment:
(Company
Name)

Part C MA
Application
Comments
60 day

Application
Section

Page
number

Description of the Issue or
Question

Type of
Suggestion CMS Decision (Accept,
Comments &
(Insertion Accept with Modification,
Recommendation(s) from Source
Deletion, or Reject, Clarify)
Revision)

2016 Part C MA & Cost Plan Application 30 Day