Response to Comments

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

1

Law Offices of 60 day
Mark S. Joffe

2

Law Offices of 60 day
Mark S. Joffe

3

Law Offices of 60 day
Mark S. Joffe

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

Health
Service
Delivery ­
Exception
Request
Template
Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the
Exception Request Template
Instructions for completing the
document and Industry Training.

Health Service
N/A
Delivery - Exception
Request Template

Comments related to CMS
Databases Used to Identify the
Provider and Facility Supply.

I believe that the administrative burden on completing the template would be reduced if CMS
provided additional clarity regarding how to complete the template, the circumstances in which
CMS will not grant an exception request, and the supporting information needed to justify an
exception request. While CMS provides extensive application training, including information
about its access review process, this training and the guidance included in the exception request
template itself, does not currently provide this clarity.
Access to CMS database identifying available providers and inclusion of places in the template
to challenge the accuracy of CMS' data. At the very end of the application process this past year
(April 28), CMS released a list of the databases that it uses to determine the closest providers to
the deficient portion of the service area. Not having this information available to applicants
precludes them from challenging the accuracy of the information in these databases. We
recommend that CMS publicize this list on an ongoing basis. We also recommend that CMS
add a link to the list on the Medicare Advantage Applications' webpage on its website. CMS
ought to re-evaluate the use of databases that have a large number of errors. From experience
during the last application review cycle, I note that the Provider of Services database includes a
number of inaccuracies with regard to facility cardiac surgery and cardiac catheterization
services. The template should be revised to give applicants guidance as to where it can explain
why it believes the data from CMS' sources is not correct. The instructions should also include
examples of the type of supporting documentation that is satisfactory or not satisfactory in
supporting the applicant's position, such as that a provider no longer exists or does not provide
the service at issue. I also believe that, if CMS rejects an applicant's argument, it needs to
provide the applicant with enough specificity so that it knows what it would need to show, if
anything, to substantiate its position.

Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the
structure of the Exception
Request template.

OMB Control Number: 0938-0935 (Expires:TBD)

The purpose of the exceptions process is to allow an applicant that does not meet CMS' time
and distance access standards to be approved consistent with§422.112(a)(l0), which includes
the general requirement that the applicant must have contract providers that are accessible
"consistent with the prevailing community patterns of health care delivery in the areas where
the network is offered." While not explicitly stated, I interpret the existing template to establish
a two-step review process. First, if an applicant has contracted with all providers within the
time and distance standards and the access requirements are still not met, the applicant can
contract with the next closest provider of the type in question and would qualify for an
exception. In other words, the template did not require any further documentation for approval.
Second, if this circumstance is not present, the applicant has the obligation to show that the
requirements are met through the prevailing patterns of care. If CMS intends to retain this
structure, I recommend that the template be expanded and expressly create these two steps.
With regard to the first step, I recommend that CMS further revise the template to allow the
applicant to assert that it has contracted with the closest provider type at issue and, as noted
above, also supplement its assertion with information that disputes the accuracy of data in
CMS' source databases.

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Revision

Accept with Modification. CMS has revised the Exception
Request template to include instructions and/or descriptions
of content within the form and changed the file format to
Excel. In addition, CMS will provide industry training and
HPMS guidance related to the exception request process
closer to the application due date.

Revision

Accept with Modification. CMS has revised the Exception
Request template to include instructions and/or descriptions
of content within the form and changed the file format to
Excel. In addition, CMS will provide industry training and
HPMS guidance related to the exception request process
closer to the application due date.

Accept. CMS has revised the Exception Request template to
include instructions and/or descriptions of content within the
form. CMS will develop training materials specifically
related to the completion and review criteria for the
Exception Request Template.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

4

Law Offices of 60 day
Mark S. Joffe

Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to criteria for In order to reduce administrative burden on applicants and on CMS, I recommend that CMS
approving and not approving
provide greater clarity either in the template or in separate instructions that explain what CMS
Exception Request.
will approve or not approve when there is a non-contracted provider closer than the one that is
part of the applicant's network. I believe the situations that give rise to this issue occur in one of
the following three circumstances: 1. Medicare beneficiaries, consistent with prevailing
patterns of care, receive the services at issue from providers located in an area farther than the
closest provider. To address this instance, CMS should provide guidance that explains the
documentation (or gives examples of the documentation) that will support this assertion. I
assume that it is insufficient to merely assert that the provider under contract is used consistent
with patterns of care. If so, the guidance should convey that point. My understanding is that the
applicant can substantiate its argument based on referral patterns that are acknowledged by
specialty provider groups or hospitals. CMS should identify these types of circumstances as
part of the guidance to applicants. 2. The CMS identified closest provider is not available to the
applicant. This can occur if the provider has retired, passed away, does not provide the service
in question, or has closed his/her panel. If my understanding of CMS' policies is correct, these
examples should be noted in the guidance accompanying the template. In addition, the
guidance should also address circumstances where the provider will not contract with any
MAO or refuses to contract with the applicant. Given that CMS' policies on what is permissible
have changed over the years, I recommend that these circumstances be addressed in the
guidance as well. The proposed template does not address any of these issues. 3. The distance
from the closest provider to the next closest provider is only marginally closer. For example, the
closest provider may be 25 miles from the deficient zip code while the next closest provider
with whom the applicant has contracted is 25.5 miles away. In prior years, I have been involved
in circumstances where CMS has approved exception requests in these circumstances. CMS'
position on the permissibility of the next closest provider when the difference is very small
should also be addressed in the guidance.

5

Law Offices of 60 day
Mark S. Joffe

Health
Service
Delivery ­
Exception
Request

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the clarity CMS' automated process can be efficient but it does not always convey clearly to the applicant
of decisions related to Exception the basis for the decision to deny the exception request. I recommend that CMS re-evaluate the
Request.
responses it gives to applicants and revise, where necessary, the explanation if it does not
convey clearly the rationale for the denial.

OMB Control Number: 0938-0935 (Expires:TBD)

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Accept with Modification. CMS will develop training
materials specifically related to the completion and review
criteria for the Exception Request process.

Accept with Modification. CMS is currently revising the
communications to the applicants regarding the status of
exception request with the goal of improving the information
provided to the applicants regarding the exception request
decision.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

6

Lewin

60 day

Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the
functionality of the Exception
Request template.

We support the transition to an Excel-based exception request (ER) template and believe the
structure of this template will clarify expectations for ERs and will increase the consistency of
submissions. To that end, we recommend CMS consider the following input to further refine
the ER submission and review process: 1.Clarify the instructions of Part I: Exception
Information We propose updating the instructions for Part I to make clear to Medicare
Advantage Organizations (MAOs) the specific sections that need to be populated and to
indicate when data, such as an SSA code, is entered incorrectly. 2.Ensure the options for the
Part III: Sources dropdown list include all sources commonly used by MAOs and consider the
feasibility of listing all sources CMS uses to identify available providers. 3.Ensure the options
for Part V: Table of Non-Contracted Providers Reason for Not Contracting dropdown list
include all reasons accepted by CMS for not contracting with an available provider or for
which CMS would like documentation from the MAO to substantiate the reason for not
contracting. We propose this addition so that MAOs may clearly communicate their reason(s)
for not contracting with a provider to CMS. CMS may want to provide guidance on allowable
versus non-allowable reasons for not contracting to accompany the list of dropdowns. 4.Enable
the submission of attachments for MAOs to provide supporting documentation (e.g. maps,
explanations, screenshots, etc.).The current template does not allow MAOs to submit
supporting documentation beyond the information required in the ER template. CMS may
consider providing the MAO the ability to include attachments with the template for additional
information.

7

Blue Cross
Blue Shield
Association

60 day

Health
Service
Delivery
Instructions

Health Service
N/A
Delivery Instructions

Comments related to deletion of BCBSA recommends that CMS retain the Specialty descriptions in the HSD instructions.
the specialty descriptions from
the HSD instructions, plans will
no longer have a ready resource
to reference.

Revision

Reject. CMS has removed the specialty descriptions from the
HSD instructions due to a duplication of this information in
various application related source documents. CMS wants to
have consistent and accurate information available to the
applicants therefore centralizing this type of information will
aid in facilitating the accuracy of the information. The
description of the Provider and Facility types will be
included in the HSD reference file.

8

Anonymous

60 day

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the
Exception Request template
dropdown capability and
instructions for completing the
template.

The Exception Request template advises there are dropdowns for Part lll: Sources. Will CMS
provide the available options prior to finalizing the template and will CMS provide overall
instructions on how to complete the Exception Request template.

Revision

9

Anonymous

60 day

Health
Service
Delivery ­
Exception
Request
Template
Health
Service
Delivery
Instructions

Health Service
N/A
Delivery Instructions

Comments related to content
within the HSD instructions
related to definitions of specialty
codes, CMS pre-check process
for HSD tables and determining
the methodology for time and
distance.

Will CMS provide definitions of specialty codes? Will CMS provide pre-checks process for the
HSD table when expanding, prior to the start of through application process? On the HSD
Instructions , page 14 - question #24 , CMS advises additional information is coming for
determining the methodology for time and distance . When will this information be available to
plan sponsors?

Revision

Accept. CMS will post the revised Exception Request
template to include instructions and/or descriptions of
content within the form in order to permit public comment.
In addition, CMS will provide industry training and HPMS
guidance related to the exception request process closer to
the application due date.
Clarify. CMS plans to provide additional information to
MAOs in the form of HSD guidance and industry training in
January.

OMB Control Number: 0938-0935 (Expires:TBD)

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Accept. CMS has revised the Exception Request template to
include instructions and/or descriptions of content within the
form and changed the file format to Excel. The public will be
able to view the descriptions of the content in order to
provide comments during the 30 day comment period.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Insertion

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

10

Health Care
Service
Corporation
(HCSC)

60 day

Attestations
for State
Licensure

Section 3.3 State
Licensure ­
attestation #6

Comments supports the
proposed new attestation
language in #6 and #7 related to
State Licensure documentation.

CMS is proposing to add a new State Licensure attestation (attestation 6), which would require
applicants to attest that their state licensure certificate(s) in each state in which the applicant
proposes to offer the managed care product automatically renews, rather than expires without
renewal. In addition, CMS is proposing to revise existing attestation 7 to require applicants to
submit license renewal information for all licenses that will renew after the MA application
submission deadline, rather than after the MA bid submission deadline, which is the current
requirement. HCSC appreciates and supports the proposed changes, and concurs with CMS’
stated expectation that the changes should reduce the number of deficiencies related to licenses
that automatically renew after the applications are due.

11

Health Care
Service
Corporation
(HCSC)

60 day

Health
Service
Delivery
Instructions

Health Service
3
Delivery Instructions

Comments are related to MA
Provider Table Instructions.

The guidance addressing completion of MA Provider Tables directs applicants to not list
contracted providers in state/county codes where the Medicare beneficiary could not reasonably
access services, and that are outside the pattern of care. In addition, we note that guidance
related to requesting HSD exceptions that previously was included in the HSD Instructions for
CY 2017 Applications (see page 12), stated that all providers listed on the Exception request
template must be listed in the HSD table in the county for which the exception is being
requested. For clarity, we recommend that CMS explicitly address the interaction between these
two requirements.

Revision

Accept. CMS has revised the CY 2018 Part C application ­
Section 2.9 Health Service Delivery Tables Instructions to
clarify for applicants the submission process for HSD tables
and Exception Requests. In addition CMS will provide
industry training and HPMS guidance related to the
exception request process closer to the application due date.

12

Health Care
Service
Corporation
(HCSC)

60 day

Health
Service
Delivery
Instructions

Health Service
N/A
Delivery Instructions

Comments are related to HSD
We note that the section titled “HSD Exceptions Guidance – Requesting Exceptions,” that was
Expectation Guidance in the CY included on page 12 of the HSD Instructions for CY 2017 Applications, does not appear to be
2017 HSD Instructions.
included in the HSD Instructions for CY 2018 Applications document. Guidance under this
section provided instruction to applicants on when and how an exception may be requested. For
clarity and to ensure applicants comply with CMS’ requirements related to exceptions requests,
we recommend that CMS continue to include these or similar instructions in the HSD guidance
document for 2018 and future years, as applicable.

Revision

Accept. CMS has revised the CY 2018 Part C application ­
Section 2.9 Health Service Delivery Tables Instructions to
clarify for applicants the submission process for HSD tables
and Exception Requests. In addition CMS will provide
industry training and HPMS guidance related to the
exception request process closer to the application due date.

13

Health Care
Service
Corporation
(HCSC)

60 day

Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the
functionality of the Exception
Request template.

CMS is proposing to convert the HSD Exceptions Request Template to an Excel format;
however, the draft template provided for review and comment is in PDF format. As a result, it
is not possible to view the “drop down” menu options included in Part III: Sources and Part IV:
Table of Non-Contracted Providers, and it is difficult to assess and evaluate the functionality of
the revised format (e.g., if the text will wrap, if the format is suitable for this type of data
reporting, etc.). To facilitate a more comprehensive review and to permit plans the best
opportunity to provide meaningful feedback, we request that CMS provide the Excel version of
the template during the subsequent 30-day Paperwork Reduction Act (PRA) comment
opportunity.

Revision

Accept. CMS will post the revised Exception Request
template to include instructions and/or descriptions of
content within the form in order to permit public comment.
In addition, CMS will provide industry training and HPMS
guidance related to the exception request process closer to
the application due date.

14

Health Care
Service
Corporation
(HCSC)

60 day

Health
Service
Delivery ­
Exception
Request
Template

Health Service
N/A
Delivery - Exception
Request Template

Comments related to the data
sources listed in the drop down
menu for Part III: Sources on
Expectation Request Template.

Under Part III: Sources, applicants will be required to utilize the drop down menus to select the
sources that were used by the applicant to identify available providers/facilities. For
consistency and accuracy, we recommend that CMS ensure the drop down menu options
correspond with the public data sources the agency uses in their review of HSD exceptions
request as specified in the “CMS Data Sources for Supply Mapping” document, which was
issued by the agency via HPMS on April 28, 2016.

Revision

Accept. CMS will post the revised Exception Request
template to include instructions and/or descriptions of
content within the form in order to permit public comment.
In addition, CMS will provide industry training and HPMS
guidance related to the exception request process closer to
the application due date.

15

United
Healthcare

60 day

N/A

N/A

Comments related to CMS
In the past, CMS has held listening sessions to discuss industry feedback and opportunities for
listening sessions to discuss the improvement based on the most recent application cycle. These listening sessions were helpful
most recent application cycle.
in improving the application process. Therefore, UnitedHealthcare respectfully requests that
CMS schedule another listening session to discuss feedback on the 2017 application process as
soon as possible.

Insertion

Clarify. CMS is reviewing the public comments and
feedback received from the CY 2017 application. CMS is
committed to improving the application process and will
identify the best method(s) for process improvements.

OMB Control Number: 0938-0935 (Expires:TBD)

25-26

N/A

Accept. CMS has revised the attestation language in the
Section 3.3 State Licensure to clarify the documentation and
process that an applicant will follow related to confirmation
of current state licensure.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

16

United
Healthcare

60 day

Timeline for
Release of
Final CY
2018
Application
Instructions
and Forms

N/A

17

United
Healthcare

60 day

18

United
Healthcare

60 day

Comments & Recommendation(s) from Source

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

N/A

Comments related to the release In 2016, the final 2017 CMS Application, forms, and Health Services Delivery (HSD) table
of final CY 2018 application
instructions were issued in January with applications due February. This timeline is
and supporting documents.
problematic for large organizations that submit high volumes of HSD tables. In order to
develop HSD Tables by the CMS deadline, UnitedHealthcare begins to build them well in
advance of the CMS deadline, several weeks before the date that final application information
is made available by UnitedHealth Group/UnitedHealthcare Applications for Part C Medicare
Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits
9/6/16 3 of 10 CMS. As a result, this requires revising/repeating work and could also require
programming changes that are difficult to accomplish in advance of the CMS application
deadline. We respectfully ask that CMS provide HSD criteria and final instruction/forms
earlier, with an October timetable being optimal, so that organizations have sufficient time to
review and ask questions before they begin implementing changes.

CMS
4.4 CMS
Certification
Form

65

Comments regarding content of
the Certification form and
suggested deletion of question
#3.

We recommend CMS amend the state certification form to delete 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. The current language will be maintained in the CMS
State Certification form.

Health
Service
Delivery
Section

34

Comments related to revising
language in attestation #5.

There are some types of providers that are on the list of types of providers to include in the MA
Facility Table that are not required to be Medicare certified, such as Speech Therapy. We
recommend the insertion of “if applicable” in this attestation, as follows: Applicant has verified
that contracted providers included in the MA Facility Table are Medicare certified, if
applicable, and the applicant certifies that it will only contract with Medicare certified
providers in the future, if applicable.

Revision

Accept. CMS revised attestation #5 in section 3.11 Health
Service Delivery to reflect that Medicare certified applies to
applicable providers and/or facilities that need to be
Medicare certified.

OMB Control Number: 0938-0935 (Expires:TBD)

3.11 Health Service
Delivery

Reject. The application schedule has been established in
order to account for the PRA process and other significant
timelines.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

19

United
Healthcare

60 day

Health
Service
Delivery
Section

3.11 Health Service
Delivery

20

United
Healthcare

60 day

Service Area 3.11 Health Service
Delivery

OMB Control Number: 0938-0935 (Expires:TBD)

34

Comments related to revising
language in attestation #9.

We recommend a revision to Attestation 9, which relates to regional preferred provider
organization (RPPO) applicants. We are proposing these revisions to make the attestation
consistent with the governing regulation that is cited as the basis for this attestation.
Specifically, we advise removing the language relating to the Applicant “only operate[ing] on a
non-network basis in those areas of a region where it is not possible to establish contracts with
a sufficient number of providers to meet Medicare network access and availability standards”
and instead using the language set forth in 42 CFR 422.2. Although this draft language
purportedly relies on 42 CFR 422.2, that regulation does not in fact contain these additional
requirements for operating on a non-network basis (nor does the applicable section of the
Social Security Act; see 42 U.S.C. 1395w–28(b)(4)). Importantly, this draft Attestation 9
language is also inconsistent with what the Social Security Act and regulations allow: RPPOs
may use methods other than written agreements to establish that access requirements are met.
(See 42 U.S.C. 1395w–22(d)(5)(c)(ii); 42 CFR 422.112(a)(1)(ii).) We suggest the following
language for Attestation 9 as it more closely tracks what 42 CFR 422.2 requires: “Applicant is
an RPPO that has established a
network of contracting providers that have agreed to a specific reimbursement for the plan’s
covered services and will pay for all covered services whether provided in or out of the network
(see 42 CFR 422.2).”

N/A

Comments related to the
accuracy of service area
data/reports.

Our CMS contract H0543 includes Los Angeles County, California in its service area. Los
Angeles (LA) County is comprised of two state and county codes (SCCs); 05210, which has
four zip codes (although it shows in our HPMS service area as a full county), and 05200, which
has dozens of zip codes, but not the four in 05210. The 05210 zip codes are in the middle of the
county and it is not clear why they comprise an SCC separate from the 05200 zip codes.
Historically, when our organization has operated in only parts of LA County, 05200 would
show as a partial county. As a result, we have filed bids with both 05210/full county and
05200/partial county included. While our bids were initially filed as full county for 2017, the
bids still included both SCCs; both showed as “Full” LA County. Having two SCCs with
different zip codes associated with this single county makes it difficult for our organization, as
well as other health plans that operate in LA County, to interpret the ACC report results used to
evaluate network adequacy. We do not believe that health plans are required to meet network
adequacy requirements in the four 05210 zip codes separately from the rest of the county.
Instead, it is our understanding that health plans are required to meet the requirements in the
county as a whole with all zips included. However, the reports are not produced that way. We
are unclear as to why LA County has two county codes associated with it and respectfully
request that CMS collapse the two county codes into one. Having the LA County service area
listed as a single county code would greatly simplify internal monitoring, reporting, and
tracking associated with this county. Alternately, we request that CMS explain why they are
separate and provide further detail around how to interpret the ACC reports for these two
ACCs, CMS’ expectations, and any difference in exception request rules if the expectation is
that we meet network adequacy in the four 05210 zip codes independently in addition to
meeting adequacy in the rest of the county zip codes.

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Reject. CMS will maintain the current language in the
attestation #9. The current language contained in Attestation
9 is consistent with CMS's expectation that RPPOs will
establish networks in those areas of the region where
providers are available to secure contracts with. In the
January 28, 2005, Final Rule, CMS provided for an
exception to network adequacy specific to RPPOs, allowing
RPPOs to use methods other than written agreements to
provide access to covered health care services. CMS
clarified that this flexibility in the network adequacy
requirements, which was subject to CMS approval, would
apply in certain situations, such as the RPPO's inability to
secure contracts with an adequate number of a specific type
of provider or providers to satisfy our comprehensive
network adequacy requirements. Consistent with 42 CFR
422.112(a)(1)(ii) and the definition of RPPOs under 42 CFR
422.2, CMS expects that an RPPO will establish networks in
those areas of the region it is being offered in where
providers are available to contract with. Therefore, the RPPO
will only operate on a non-network basis in those areas of the
region where it is not possible to establish contracts with a
sufficient number of providers to meet Medicare network
access and availability standards. CMS has revised the
language in Attestation 9 to reference both 42 CFR 422.2
and 422.112(a)(1)(ii).
Reject. The zip codes associated with Los Angeles County,
California have been in place for several application cycles
and several MAOs are operational within Los Angles County
,California.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

21

United
Healthcare

60 day

Inaccurate
HSD Instructions and N/A
and Outdated MA Provider and
Sources of
Facility Tables
Data on
Providers and
Facility
Services

Related to the accuracy of the
data sources used to identify
providers and facilities in
relation to network adequacy.

The provider and facility data sources CMS is relying on to determine if there are deficiencies
in an MAO’s network are inaccurate and outdated. Every one of the provider and facility data
sources listed by CMS in the April 28, 2016 document titled, “CMS Data Sources for Supply
Mapping” has issues with inaccurate addresses, provider specialties and facility services,
providers that are retired, deceased or moved out of the area, or facilities that are out of
business, changed their name or merged with another entity. For example, we have noticed that
the Medicare.gov website often lists services available at an acute inpatient hospital even
though the hospital operating certificate may not be approved by Department of Health to
provide those services. Additionally, it appears a hospital can remain on these lists even after
CMS is notified that it does not actually provide those services. Due to these significant
concerns related to the accuracy of the data sources used by CMS, we respectfully request that
CMS consider ways to ensure that all provider data sources used are accurate, up-to-date and
publicly available. UnitedHealthcare believes it would be beneficial for all MAOs if CMS
released one centralized and updated source of providers / facilities / suppliers (e.g., enhancing
or improving Medicare.gov) rather than multiple data sources. This may make it easier for
CMS to maintain accurate and updated provider data. A future, centralized data source should
include processes to remove providers who are no longer practicing the specialties listed, who
are no longer accepting Medicare, whose office locations are no longer correct, or who are
otherwise not available.

22

United
Healthcare

60 day

Health
Service
Delivery
Instructions

HSD Exception
Request Template

N/A

Comments related to the draft
CY 2018 HSD Instruction
document that do not reference
the Exception Request template.

The draft HSD instructions and exception request template for 2018 that CMS released for
Revision
comment do not include instructions for completing exception requests or the criteria CMS will
use to approve or deny exception requests. UnitedHealthcare respectfully requests that CMS
issue revised exception request instructions and template as well as provide MAOs a review
and comment period to ensure the revised instructions and template are clear, correct, and
internally consistent. It is critical that MAOs have an opportunity to review and comment on
these components of the application materials and process because for the last application
cycle, CMS made numerous changes to the instructions, exception request template, and
process that were unclear, incomplete, and inconsistent with the regulations.

Accept. CMS has revised the CY 2018 Part C application ­
Section 2.9 Health Service Delivery Tables Instructions to
clarify for applicants the submission process for HSD tables
and Exception Requests. CMS will post the revised
Exception Request template to include instructions and/or
descriptions of content within the form in order to permit
public comment.

23

United
Healthcare

60 day

Health
Service
Delivery
Instructions

HSD Table
Instructions /MA
Provider Table

N/A

Comments related to removing
the descriptions of both MA
provider and facility in the HSD
instructions.

UnitedHealthcare has concerns regarding CMS’ removal of the descriptions of Primary Care
Revision
provider types and MA Facility Types. Instead, in the HSD Guidance and Methodology
document, CMS refers applicants to information posted on their website. Without a direct link
to a currently posted document or excerpts from the applicable document included in the HSD
instructions, it becomes difficult to determine whether there are proposed changes in CMS'
definitions regarding these providers and facilities. Additionally, a cross-reference to another
document may create additional burden or confusion for applicants if CMS alters the relevant
definitions of the HSD Guidance and Methodology document at a later date without notice. We
recommend that CMS include the applicable definitions and instructions related to these
providers and facilities in the HSD instructions instead of providing a cross-reference to CMS'
website. We continue to support CMS' inclusion of Physician Assistants and Nurse
Practitioners as Primary Care Providers. While the Descriptions of the MA Provider Types
section has been removed from the draft 2018 HSD instructions, we want to ensure that
physician extenders (assistants and practitioners) will still be counted as Primary Care
Providers in applicants' submissions in accordance with state requirements.

Clarify. CMS has removed the specialty descriptions from
the HSD instructions due to a duplication of this information
in various application related source documents. CMS wants
to have consistent and accurate information available to the
applicants therefore centralizing this type of information will
aid in facilitating the accuracy of the information. The
description of the Provider and Facility types will be
included in the HSD reference file. CMS has revised the CY
2018 Part C application - Section 2.9 Health Service
Delivery Tables Instructions to clarify for applicants the
submission process for HSD tables and Exception Requests.
In addition CMS will provide industry training and HPMS
guidance related to the exception request process closer to
the application due date.

OMB Control Number: 0938-0935 (Expires:TBD)

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Clarify. CMS plans to provide additional information to
MAOs in the form of HSD guidance and industry training in
January.

Comment
Number

Source of
Comment:
(Company
Name)

2018 MA Application
Application Part
60 day or
30 day

24

United
Healthcare

60 day

Transplant
N/A
Facilities List
Format

N/A

Request for CMS to provide
transplant facilities list in file
format such as .txt or
Excel/Access format instead of
PDF file.

UnitedHealthcare appreciates CMS’ inclusion of a downloadable certified transplant facilities
list. However, the list is currently only available in a PDF format, which requires considerable
manual manipulation to convert to Microsoft Excel or Access for automated reporting. We
request that CMS produce the certified transplant list in a .txt or Excel/Access format similar to
the other website posted downloadable files of CMS certified providers (e.g., Hospital, Home
Health, Suppliers) in order to streamline this process and eliminate the need for manual
manipulation. While the 2018 instructions list a specialty code of 062 for Heart/Lung
Transplant Programs, the list of Medicare-Approved Transplant Programs on CMS' website
does not include heart/lung transplant programs (only heart-only and lung-only). We request
additional clarification regarding the availability of a heart/lung transplant program list or if
CMS is not currently using this category.

25

United
Healthcare

60 day

Facility Table N/A
ServicesAccess to
CMS
Information

N/A

Request for CMS to automate
data that is requested on HSD
MA Facility tables such as
Medicare certified beds for
hospitals.

CMS often requires information regarding facilities that is not readily available to all MAOs for
use in an automated fashion; for example, the number of Medicare certified beds for hospitals,
skilled nursing facilities, intensive care units, and inpatient psychiatric facilities. CMS should
provide a central resource from which MAOs can obtain bed counts, by hospital location, so
that this information is consistent and available to all health plans. We request that CMS
provide information so that it is downloadable in Excel or other downloadable data formats.
This will assist plans in their automated production of HSD tables and population of these
fields with accurate CMS information.

OMB Control Number: 0938-0935 (Expires:TBD)

Application Section Applicati Description of the Issue or
(Number/ Header)
on Page Question
Number

Comments & Recommendation(s) from Source

Type of
Suggestion
(Insertion,
Deletion, or
Revision)
Revision

CMS Decision (Accept, Accept with Modification, Reject,
Clarify)

Revision

Reject: We would suggest that MAOs identify sources for
obtaining and confirming this information such as facility
websites. No government data base is going to be as current
and up to date as the facility's own official record in the
CEO or CFO's office.

Reject. The MAO has identified that the file is only provided
in a PDF format. We are unable to confirm that another file
format can be made available for this document. In addition,
the HSD Reference file will provide the information needed
for MAOs related to the use of provider and facility codes.