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pdfPART C -MEDICARE ADVANTAGE
and 1876 COST PLAN EXPANSION
APPLICATION
For all new applicants and existing Medicare Advantage organizations
seeking to expand a service area: Coordinated Care Plans, Private Feefor-Service Plans, Medicare Savings Account plans, and Employer
Group Waiver Plans
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)
In accordance with 42 CFR 422.4(c) and Chapter 4 section 10.15 of the MMCM, in
order to offer a Medicare Advantage Coordinated Care Plan (CCPs) in an area, a
Medicare Advantage organization must offer qualified Part D coverage meeting 42
CFR 423.104 in that plan or in another Medicare Advantage plan in the same area.
Therefore, CCP applicants may need to submit a separate Part D application (in
connection with this Part C Application) to offer Part D prescription drug benefits
as a condition for approval of this application.
DISCLAIMER: CMS will only accept applications appropriately submitted through the
Health Plan Management System. CMS does not accept paper applications.
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 (Expires: TBD). The time required to complete this information collection is estimated to
average 33 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. Expiration: TBD
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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) ................................................. 7
Submitting Notice of Intent to Apply (NOIA) .................................................... 7
Additional Information ....................................................................................... 8
Due Dates for Applications – Medicare Advantage and Medicare Cost Plans 10
Request to Modify a Pending Application ........................................................ 11
Application Determination and Appeal Rights ................................................. 11
INSTRUCTIONS .......................................................................... 12
2.1.
2.2.
Overview ........................................................................................................... 12
Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans
(EGWPs) ........................................................................................................... 12
2.3. Applicants Seeking to Offer Employer/Union Direct Contract MAO.............. 13
2.4. Applicants Seeking to Offer Special Needs Plans (SNPs)................................ 13
2.5. Applicants Seeking to Expand Medicare Cost Plans ........................................ 13
2.6. Applicants Seeking to Serve Partial Counties .................................................. 14
2.7. Types of Applications ....................................................................................... 14
2.8. Chart of Required Attestations by Type of Applicant ...................................... 15
2.9. Document (Upload) Submission Instructions ................................................... 17
2.10. MA Part D (MA-PD) Prescription Drug Benefit Instructions .......................... 17
3.
ATTESTATIONS ......................................................................... 18
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.
3.15.
3.16.
3.17.
Management, Experience, and History ............................................................. 20
Administrative Management ............................................................................. 20
State Licensure .................................................................................................. 21
Program Integrity .............................................................................................. 23
Fiscal Soundness ............................................................................................... 23
Service Area ...................................................................................................... 24
CMS Provider Participation Contracts & Agreements ..................................... 26
Contracts for Administrative & Management Services .................................... 27
Quality Improvement Program ......................................................................... 28
Marketing .......................................................................................................... 29
Eligibility, Enrollment, and Disenrollment ....................................................... 29
Working Aged Membership ............................................................................. 30
Claims ............................................................................................................... 31
Communications between MAO and CMS ...................................................... 32
Grievances......................................................................................................... 34
Organization Determination and Appeals ......................................................... 35
Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
CMS issued guidance on 07/23/2007 and 8/28/2007; 2008 Call Letter ........... 37
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3.18.
3.19.
3.20.
3.21.
3.22.
3.23.
3.24.
4.
Continuation Area ............................................................................................. 38
Part C Application Certification ....................................................................... 39
Access to Services (PFFS) ................................................................................ 39
Claims Processing (PFFS and MSA) ................................................................ 43
Payment Provisions (PFFS and MSA) .............................................................. 45
General Administration/Management (MSA) .................................................. 47
Past Performance .............................................................................................. 49
Document Upload Templates ....................................................... 50
4.1.
4.2.
4.3.
4.4.
4.5.
History/Structure/Organizational Charts .......................................................... 50
Minimum Enrollment Waiver Request Upload Document .............................. 51
Two Year Prohibition Waiver Request Upload Document .............................. 52
CMS State Certification Form .......................................................................... 53
Part C Application Certification Form .............................................................. 59
4.6.
4.7.
4.8.
RPPO State Licensure Table ............................................................................. 60
RPPO State Licensure Attestation .................................................................... 61
Partial County Justification ............................................................................... 62
5.
APPENDIX I: Solicitations for Special Needs Plan (SNP)
Application ..................................................................................... 64
5.1.
5.2.
5.3.
5.4.
5.5.
5.6.
5.7.
5.8.
5.9.
5.10.
5.11.
5.12.
5.13.
5.14.
5.15.
6.
Overview ........................................................................................................... 64
SNP Application Types..................................................................................... 65
Renewal SNPs that are Not Expanding their Service Area: ............................. 66
D-SNP State Medicaid Agency(ies) Contract(s): Attestation and Uploads...... 67
I-SNP: Attestations and Uploads ...................................................................... 69
C-SNP, D-SNP and I-SNP ESRD Waiver Request: Attestation and Upload ... 70
MOC: Attestation and Uploads ......................................................................... 70
Health Risk Assessment: Attestations .............................................................. 71
SNP Quality Improvement Program: Attestations ............................................ 73
Past Performance Attestation ............................................................................ 75
D-SNP State Medicaid Agency Contract Matrix .............................................. 76
Special Needs Plan (SNP) Contract Review Matrix ......................................... 81
I-SNP Upload Documents................................................................................. 84
ESRD Waiver Request Upload Document ....................................................... 88
MOC Matrix Upload Document for Initial Application and Renewal ............. 90
APPENDIX II: Employer/Union-Only Group Waiver Plans
(EGWPs) MAO “800 Series” ....................................................... 98
6.1.
6.2.
6.3.
6.4.
Background ....................................................................................................... 98
Instructions ........................................................................................................ 98
Request for Additional Waivers/Modification of Requirements (Optional) .... 99
Attestations ..................................................................................................... 100
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7.
APPENDIX III: Employer/Union Direct Contract for MA ... 105
7.1.
7.2.
7.3.
7.4.
7.5.
Background ..................................................................................................... 105
Instructions ...................................................................................................... 105
Request for Additional Waivers/Modification of Requirements (Optional) .. 106
Attestations ..................................................................................................... 107
Part C Financial Solvency & Capital Adequacy Documentation For Direct
Contract MAO applicants ............................................................................... 111
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1.
GENERAL INFORMATION
1.1. 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.
Pursuant to 42 CFR 422.4, the MA program offers several kinds of plans and health care
choices, including a coordinated care plans, Medicare Savings Account (MSA) plans, or
Private Fee-for-Service (PFFS) 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)
Health Maintenance Organizations (HMOs) with or without a Point of
Service (POS) benefit
Local Preferred Provider Organizations (LPPOs)
Regional Preferred Provider Organizations (RPPOs)
Special Needs Plans (SNPs)
Private Fee-for-Service (PFFS) plans
Medical Savings Account (MSA) plans
Employer Group Waiver plans (EGWPs)
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.
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.
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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/Title42/42
cfr422_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.
The following are key references about the Medicare cost plans:
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/Title42/42c
fr417_main_02.tpl
Centers for Medicare & Medicaid Services (CMS) Web site:
http://www.cms.gov/MedicareCostPlans/
1.4. 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.
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 submit an inquiry by going to https://dmao.lmi.org and
clicking on the MA Applications tab. Please note: this is a webpage, not an email
address. Below is a list of CMS RO contacts (This information is also available at:
https://www.cms.gov/RegionalOffices/).
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1.5. The Health Plan Management System (HPMS)
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.
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.
Please note that it is CMS’ expectation that the MA and Medicare Cost Plan Application
Contact is a direct employee of the applicant.
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 follow the guidance as indicated in the memos.
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 MA product, or submitting a PFFS network transition application must complete
a nonbinding NOIA. 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://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Dataand-Systems/HPMS/UserIDProcess.html. Upon approval of the CMS User ID request,
the applicant will receive a CMS User ID(s) and password(s) for HPMS access. Existing
MAOs requesting service area expansions do not need to apply for a new contract
number.
Medicare Cost Plans
No initial or new 1876 Cost Plan applications can be accepted by CMS during this
application cycle. CMS will accept applications to expand service areas of existing 1876
Cost Plans for CY 2020 in accordance with 42 CFR 417.402. During the CMS review of
these applications, the most current data will be employed to apply the Cost Plan
Competition Requirements with regard to this type of application. CMS will make a
determination whether an application of this type cannot be processed during this
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application cycle to the extent that the expansion application is for a requested service
area or portions of a service area in which at least two competing Medicare Advantage
local coordinated care plans or two Medicare Advantage Regional PPO coordinated care
plans meeting specified enrollment thresholds are available. If this is the case, the
applicant will be informed and the application withdrawn from further processing and
review.
Existing Cost contractors requesting service area expansions should not apply for a new
Cost contract number.
1.7. Additional Information
1.7.1.
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 their 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 they intend 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 their plan structures and
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 their MA or Medicare Cost Plan benefit and
the BPT software to define their 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 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 2020.
* 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.
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1.7.2. 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 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/Research-Statistics-Data-and-Systems/CMS-InformationTechnology/mapdhelpdesk/index.html. The MA Help Desk is the primary contact for all
issues related to the physical submission of transaction files to CMS.
1.7.3. 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.
1.7.4. 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.
Please submit the fully completed Payment Information form and the following
documents to CMS:
Copy of a voided check or a letter from bank confirming the routing and account
information.
W-9 Form.
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The completed Payment Information Form and supporting documentation must be
emailed to [email protected] by the date the
completed applications are due to CMS. The subject line of the email should be
“Payment Information Form for [insert contract number]”, and the plan should specify
the effective date (month and year) in the body of the email.
If the applicant has questions about this form, please contact Louise Matthews at (410)
786-6903.
1.8. Due Dates for Applications – Medicare Advantage and Medicare Cost Plans
Applications must be submitted by February 12, 2020. CMS will not review applications
received after this date and time. Applicant’s 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) and Medicare Cost Plan
application review process:
APPLICATION AND BID REVIEW PROCESS*
Date
December 2, 2019
January 8, 2020
Milestone
Recommended date by which applicants should submit
their Notice of Intent to Apply Form to CMS to ensure
access to Health Plan Management System (HPMS) by
the date applications are released.
CMS User ID form due to CMS
Final Applications Posted by CMS
January 24, 2020
Deadline for NOIA form submission to CMS
February 12, 2020
Completed Applications due to CMS
November 13, 2019
May 1, 2020
May 12, 2020
June 1, 2020
Plan Creation module, Plan Benefit Package (PBP), and
Bid Pricing Tool (BPT) available on HPMS.
PBP/BPT Upload Module available in HPMS
Release of CY 2021 Formulary Submission Module.
Bids due to CMS.
Late August 2020
CMS completes review and approval of bid data.
April 2020
CMS executes MA and MA-PD contracts with
organizations whose bids are approved and who
otherwise meet CMS requirements.
Annual Coordinated Election Period begins for CY 2021
plans.
September 2020
Mid October 2020
* Note: All dates listed above are subject to change.
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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. 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:
Withdrawal from individual Medicare market counties (keeping Medicare
employer group counties, e.g., 800 series plan(s))
Withdrawal from employer group counties (keeping the individual Medicare
market counties)
Withdrawal of the entire application.
Withdrawal of specifically named counties from both individual Medicare and
employer group markets
Applicants shall submit the request in PDF format to https://dmao.lmi.org/ under the MA
Applications tab. Please note: this is a webpage, not an email address. Applicants should
also send a copy of the letter via e-mail to the Regional office Account Manager.
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 and Cost Plan 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 1, 2020
(tentative date) in order to qualify for a Medicare contract to begin January 1, 2021.
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2. INSTRUCTIONS
2.1. Overview
Applicants must complete the 2021 MA or Medicare Cost Plan Service Area Expansion
application within HPMS as instructed. CMS will only accept submissions using this
current 2021 version of the MA/Cost Plan application. All uploaded documentation must
contain the appropriate CMS-issued contract number.
In preparing a response to the prompts throughout this application, the applicant must
attest “Yes” or “No.” In some instances, applicants will have the opportunity to attest
“N/A” if the attestation does not apply. Applicants are also asked to provide various
upload documents 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.
CMS may verify an applicant’s readiness and compliance with Medicare requirements at
any time (both prior to and after the start of the contract year) through on-site visits at the
applicant’s facilities as well as through other program monitoring. Failure to meet the
requirements represented in this application and to operate MA or Medicare Cost plans
consistent with the applicable statutes, regulations, 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.
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.
see Please complete and upload this document into HPMS.
SNP Contract Name (as provided in HPMS)__________________________
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SNP CMS Contract Number______________________
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.
All SNPs are required to develop and implement a Model of Care per regulations at: 42
CFR §422.101(f) and 42 CFR§422.152(g).
1. Description of the SNP Population:Element A: Description of the Overall SNP Population: The identification and
comprehensive description of the SNP-specific population is an integral component of the
MODEL OF CARE because all of the other elements depend on the firm foundation of a
comprehensive population description. The organization must provide information about its
local target population in the service areas covered under the contract. Information about
national population statistics is insufficient. It must provide an overview that fully addresses
the full continuum of care of current and potential SNP beneficiaries, including end-of-life
needs and considerations, if relevant to the target population served by the SNP. The
description of the SNP population must include, but not be limited to, the following:
Clear documentation of how the health plan staff determines or will determine, verify, and
track eligibility of SNP beneficiaries.
A detailed profile of the medical, social, cognitive, environmental, living conditions, and
co-morbidities associated with the SNP population in the plan’s geographic service area.
Identification and description of the health conditions impacting SNP beneficiaries,
including specific information about other characteristics that affect health such as,
population demographics (e.g. average age, gender, ethnicity, and potential health
disparities associated with specific groups such as: language barriers, deficits in health
literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations,
other).
Define unique characteristics for the SNP population served:
C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a C-SNP?
Include limitations and barriers that pose potential challenges for these C-SNP
beneficiaries.
D-SNP: What are the unique health needs for beneficiaries enrolled in a D-SNP? Include
limitations and barriers that pose potential challenges for these D-SNP beneficiaries.
I-SNP: What are the unique health needs for beneficiaries enrolled in an I-SNP? Include
limitations and barriers that pose potential challenges for these I-SNP beneficiaries as
well as information about the facilities and/or home and community-based services in
which your beneficiaries reside.
Element B: Sub-Population: Most Vulnerable Beneficiaries
As a SNP, you must include a complete description of the specially-tailored services for
beneficiaries considered especially vulnerable using specific terms and details (e.g.,
members with multiple hospital admissions within three months, “medication spending
above $4,000”). The description must differentiate between the general SNP population and
that of the most vulnerable members, as well as detail additional benefits above and beyond
those available to general SNP members. Other information specific to the description of the
most vulnerable beneficiaries must include, but not be limited to, the following:
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A description of the internal health plan procedures for identifying the most vulnerable
beneficiaries within the SNP.
A description of the relationship between the demographic characteristics of the most
vulnerable beneficiaries with their unique clinical requirements. Explain in detail how
the average age, gender, ethnicity, language barriers, deficits in health literacy, poor
socioeconomic status and other factor(s) affect the health outcomes of the most
vulnerable beneficiaries.
The identification and description of the established partnerships with community
organizations that assist in identifying resources for the most vulnerable beneficiaries,
including the process that is used to support continuity of community partnerships and
facilitate access to community services by the most vulnerable beneficiaries and/or their
caregiver(s).
2. Care Coordination:
Regulations at 42 CFR §422.101(f)(ii)-(v) and 42 CFR §422.152(g)(2)(vii)-(x) require all
SNPs to coordinate the delivery of care, and measure the effectiveness of the MODEL OF
CARE delivery of care coordination. Care coordination helps ensure that SNP beneficiaries’
healthcare needs, preferences for health services and information sharing across healthcare
staff and facilities are met over time. Care coordination maximizes the use of effective,
efficient, safe, and high-quality patient services that ultimately lead to improved healthcare
outcomes, including services furnished outside the SNP’s provider network as well as the care
coordination roles and responsibilities overseen by the beneficiaries’ caregiver(s). The
following MODEL OF CARE sub-elements are essential components to consider in the
development of a comprehensive care coordination program; no sub-element must be
interpreted as being of greater importance than any other. All five sub-elements below, taken
together, must comprehensively address the SNPs’ care coordination activities.
A. SNP Staff Structure
Fully define the SNP staff roles and responsibilities across all health plan functions that
directly or indirectly affect the care coordination of beneficiaries enrolled in the SNP.
This includes, but is not limited to, identification and detailed explanation of:
Specific employed and/or contracted staff responsible for performing administrative
functions, such as: enrollment and eligibility verification, claims verification and
processing, other.
Employed and/or contracted staff that perform clinical functions, such as: direct
beneficiary care and education on self-management techniques, care coordination,
pharmacy consultation, behavioral health counseling, other.
Employed and/or contracted staff that performs administrative and clinical oversight
functions, such as: license and competency verification, data analyses to ensure
appropriate and timely healthcare services, utilization review, ensuring that providers
use appropriate clinical practice guidelines and integrate care transitions protocols.
Provide a copy of the SNP’s organizational chart that shows how staff responsibilities
identified in the MODEL OF CARE are coordinated with job titles. If applicable,
include a description of any instances when a change to staff title/position or level of
accountability was required to accommodate operational changes in the SNP.
Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical staff
functions.
Describe how the SNP conducts initial and annual MODEL OF CARE training for its
employed and contracted staff, which may include, but not be limited to, printed
instructional materials, face-to-face training, web-based instruction, and audio/videoconferencing.
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Describe how the SNP documents and maintains training records as evidence to ensure
MODEL OF CARE training provided to its employed and contracted staff was
completed. For example, documentation may include, but is not limited to: copies of
dated attendee lists, results of MODEL OF CARE competency testing, web-based
attendance confirmation, and electronic training records.
Explain any challenges associated with the completion of MODEL OF CARE training
for SNP employed and contracted staff and describe what specific actions the SNP will
take when the required MODEL OF CARE training has not been completed or has been
found to be deficient in some way.
B. Health Risk Assessment Tool (HRAT)
Regulations at 42 CFR §422.101(f)(i); 42 CFR §422.152(g)(2)(iv) require that all SNPs
conduct a Health Risk Assessment for each individual enrolled in the SNP. The quality and
content of the HRAT should identify the medical, functional, cognitive, psychosocial and
mental health needs of each SNP beneficiary. The content of, and methods used to conduct
the HRAT have a direct effect on the development of the Individualized Care Plan and
ongoing coordination of Interdisciplinary Care Team activities; therefore, it is imperative that
the MODEL OF CARE include the following:
A clear and detailed description of the policies and procedures for completing the HRAT
including:
Description of how the HRAT is used to develop and update, in a timely manner, the
Individualized Care Plan (MODEL OF CARE Element 2C) for each beneficiary and
how the HRAT information is disseminated to and used by the Interdisciplinary Care
Team (MODEL OF CARE Element 2D).
Detailed explanation for how the initial HRAT and annual reassessment are conducted
for each beneficiary.
Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the
results of the HRAT, including the mechanisms to ensure communication of that
information to the Interdisciplinary Care Team, provider network, beneficiaries and/or
their caregiver(s), as well as other SNP personnel that may be involved with
overseeing the SNP beneficiary’s plan of care. If stratified results are used, include a
detailed description of how the SNP uses the stratified results to improve the care
coordination process.
C. Individualized Care Plan (ICP)
Regulations at 42 CFR §422.101(f)(ii); 42 CFR §422.152(g)(2)(iv) require that all SNPs
must develop and implement an ICP for each individual enrolled in the SNP.
The ICP components must include, but are not limited to: beneficiary self-management
goals and objectives; the beneficiary’s personal healthcare preferences; description of
services specifically tailored to the beneficiary’s needs; roles of the beneficiaries’
caregiver(s); and identification of goals met or not met.
When the beneficiary’s goals are not met, provide a detailed description of the process
employed to reassess the current ICP and determine appropriate alternative actions.
Explain the process and which SNP personnel are responsible for the development of the
ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is involved in its
development and how often the ICP is reviewed and modified as the beneficiary’s
healthcare needs change. If a stratification model is used for determining SNP
beneficiaries’ health care needs, then each SNP must provide a detailed explanation of
how the stratification results are incorporated into each beneficiary’s ICP.
Describe how the ICP is documented and updated as well as, where the documentation is
maintained to ensure accessibility to the ICT, provider network, beneficiary and/or
caregiver(s).
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Explain how updates and/or modifications to the ICP are communicated to the beneficiary
and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel and
other stakeholders as necessary.
D. Interdisciplinary Care Team (ICT)
Regulations at 42 CFR §422.101(f)(iii); 42 CFR §422.152(g)(2)(iv) require all SNPs to use
an ICT in the management of care for each individual enrolled in the SNP.
Provide a detailed and comprehensive description of the composition of the ICT; include
how the SNP determines ICT membership and a description of the roles and
responsibilities of each member. Specify how the expertise and capabilities of the ICT
members align with the identified clinical and social needs of the SNP beneficiaries, and
how the ICT members contribute to improving the health status of SNP beneficiaries. If a
stratification model is used for determining SNP beneficiaries’ health care needs, then
each SNP must provide a detailed explanation of how the stratification results are used to
determine the composition of the ICT.
Explain how the SNP facilitates the participation of beneficiaries and their caregivers as
members of the ICT.
Describe how the beneficiary’s HRAT (MODEL OF CARE Element 2B) and ICP
(MODEL OF CARE Element 2C) are used to determine the composition of the ICT;
including those cases where additional team members are needed to meet the unique
needs of the individual beneficiary.
Explain how the ICT uses healthcare outcomes to evaluate established processes to
manage changes and/or adjustments to the beneficiary’s health care needs on a
continuous basis.
Identify and explain the use of clinical managers, case managers or others who play
critical roles in ensuring an effective interdisciplinary care process is being conducted.
Provide a clear and comprehensive description of the SNP’s communication plan that
ensures exchanges of beneficiary information is occurring regularly within the ICT,
including not be limited to, the following:
Clear evidence of an established communication plan that is overseen by SNP personnel
who are knowledgeable and connected to multiple facets of the SNP MODEL OF
CARE. Explain how the SNP maintains effective and ongoing communication between
SNP personnel, the ICT, beneficiaries, caregiver(s), community organizations and other
stakeholders.
The types of evidence used to verify that communications have taken place, e.g., written
ICT meeting minutes, documentation in the ICP, other.
How communication is conducted with beneficiaries who have hearing impairments,
language barriers and/or cognitive deficiencies.
E. Care Transitions Protocols
Regulations at 42 CFR §422.101(f)(2)(iii-v); 42 CFR §422.152(g)(2)(vii-x) require all SNPs
to coordinate the delivery of care.
Explain how care transitions protocols are used to maintain continuity of care for SNP
beneficiaries. Provide details and specify the process and rationale for connecting the
beneficiary to the appropriate provider(s).
Describe which personnel (e.g., case manager) are responsible for coordinating the care
transition process and ensuring that follow-up services and appointments are scheduled
and performed as defined in MODEL OF CARE Element 2A.
Explain how the SNP ensures elements of the beneficiary’s ICP are transferred between
healthcare settings when the beneficiary experiences an applicable transition in care. This
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must include the steps that need to take place before, during and after a transition in care
has occurred.
Describe, in detail, the process for ensuring the SNP beneficiary and/or caregiver(s) have
access to and can adequately utilize the beneficiaries’ personal health information to
facilitate communication between the SNP beneficiary and/or their caregiver(s) with
healthcare providers in other healthcare settings and/or health specialists outside their
primary care network.
Describe how the beneficiary and/or caregiver(s) will be educated about indicators that
his/her condition has improved or worsened and how they will demonstrate their
understanding of those indicators and appropriate self-management activities.
Describe how the beneficiary and/or caregiver(s) are informed about who their point of
contact is throughout the transition process.
3.
SNP Provider Network
The SNP Provider Network is a network of healthcare providers who are contracted to provide
health care services to SNP beneficiaries. The SNP is responsible for a network description
that must include relevant facilities and practitioners necessary to address the unique or
specialized health care needs of the target population as identified in MODEL OF CARE 1,
and provide oversight information for all of its network types. Each SNP is responsible for
ensuring their MODEL OF CARE identifies, fully describes, and implements the following for
its SNP Provider Network:
A. Specialized Expertise
Regulations at 42 CFR§422.152(g)(2)(vi) require SNPs to demonstrate that the provider
network has specialized clinical expertise in delivery of care to beneficiaries.
Provide a complete and detailed description of the specialized expertise available to SNP
beneficiaries in the SNP provider network that corresponds to the SNP population
identified in MODEL OF CARE Element 1.
Explain how the SNP oversees its provider network facilities and ensures its providers are
actively licensed and competent (e.g., confirmation of applicable board certification) to
provide specialized healthcare services to SNP beneficiaries. Specialized expertise may
include, but is not limited to: internal medicine, endocrinologists, cardiologists,
oncologists, mental health specialists, other.
Describe how providers collaborate with the ICT (MODEL OF CARE Element 2D) and
the beneficiary, contribute to the ICP (MODEL OF CARE Element 2C) and ensure the
delivery of necessary specialized services. For example, describe: how providers
communicate SNP beneficiaries’ care needs to the ICT and other stakeholders; how
specialized services are delivered to the SNP beneficiary in a timely and effective way;
and how reports regarding services rendered are shared with the ICT and how relevant
information is incorporated into the ICP.
B. Use of Clinical Practice Guidelines & Care Transitions Protocols
Regulations at 42 CFR §422.101 (f)(2)(iii)-(v);42 CFR§422.152(g)(2)(ix)require SNPs to
demonstrate the use of clinical practice guidelines and care transition protocols.
Explain the processes for ensuring that network providers utilize appropriate clinical
practice guidelines and nationally-recognized protocols. This may include, but is not
limited to: use of electronic databases, web technology, and manual medical record review
to ensure appropriate documentation.
Define any challenges encountered with overseeing patients with complex healthcare
needs where clinical practice guidelines and nationally-recognized protocols may need to
be modified to fit the unique needs of vulnerable SNP beneficiaries. Provide details
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regarding how these decisions are made, incorporated into the ICP (MODEL OF CARE
Element 2C), communicated with the ICT (MODEL OF CARE Element 2D) and acted
upon.
Explain how SNP providers ensure care transitions protocols are being used to maintain
continuity of care for the SNP beneficiary as outlined in MODEL OF CARE Element 2E.
C. MODEL OF CARE Training for the Provider Network
Regulations at 42 CFR§422.101(f)(2)(ii) require that SNPs conduct MODEL OF CARE
training for their network of providers.
Explain, in detail, how the SNP conducts initial and annual MODEL OF CARE training
for network providers and out-of-network providers seen by beneficiaries on a routine
basis. This could include, but not be limited to: printed instructional materials, face-to-face
training, web-based instruction, audio/video-conferencing, and availability of instructional
materials via the SNP plans’ website.
Describe how the SNP documents and maintains training records as evidence of MODEL
OF CARE training for their network providers. Documentation may include, but is not
limited to: copies of dated attendee lists, results of MODEL OF CARE competency
testing, web-based attendance confirmation, electronic training records, and physician
attestation of MODEL OF CARE training.
Explain any challenges associated with the completion of MODEL OF CARE training for
network providers and describe what specific actions the SNP Plan will take when the
required MODEL OF CARE training has not been completed or is found to be deficient in
some way.
4. MODEL OF CARE Quality Measurement & Performance Improvement:
Regulations at 42 CFR §422.152(g) require that all SNPs conduct a quality improvement
program that measures the effectiveness of its MODEL OF CARE. The goals of performance
improvement and quality measurement are to improve the SNP’s ability to deliver healthcare
services and benefits to its SNP beneficiaries in a high-quality manner. Achievement of those
goals may result from increased organizational effectiveness and efficiency by incorporating
quality measurement and performance improvement concepts used to drive organizational
change. The leadership, managers and governing body of a SNP organization must have a
comprehensive quality improvement program in place to measure its current level of
performance and determine if organizational systems and processes must be modified based
on performance results.
A. MODEL OF CARE Quality Performance Improvement Plan
Explain, in detail, the quality performance improvement plan and how it ensures that
appropriate services are being delivered to SNP beneficiaries. The quality performance
improvement plan must be designed to detect whether the overall MODEL OF CARE
structure effectively accommodates beneficiaries’ unique healthcare needs. The
description must include, but is not limited to, the following:
The complete process, by which the SNP continuously collects, analyzes, evaluates and
reports on quality performance based on the MODEL OF CARE by using specified
data sources, performance and outcome measures. The MODEL OF CARE must also
describe the frequency of these activities.
Details regarding how the SNP leadership, management groups and other SNP
personnel and stakeholders are involved with the internal quality performance process.
Details regarding how the SNP-specific measurable goals and health outcomes
objectives are integrated in the overall performance improvement plan (MODEL OF
CARE Element 4B).
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Process it uses or intends to use to determine if goals/outcomes are met, there must be
specific benchmarks and timeframes, and must specify the re-measurement plan for
goals not achieved.
B. Measureable Goals & Health Outcomes for the MODEL OF CARE
Identify and clearly define the SNP’s measureable goals and health outcomes and
describe how identified measureable goals and health outcomes are communicated
throughout the SNP organization. Responses must include but not be limited to, the
following:
Specific goals for improving access and affordability of the healthcare needs outlined
for the SNP population described in MODEL OF CARE Element 1.
Improvements made in coordination of care and appropriate delivery of services
through the direct alignment of the HRAT, ICP, and ICT.
Enhancing care transitions across all healthcare settings and providers for SNP
beneficiaries.
Ensuring appropriate utilization of services for preventive health and chronic
conditions.
Identify the specific beneficiary health outcomes measures that will be used to measure
overall SNP population health outcomes, including the specific data source(s) that will be
used.
Describe, in detail, how the SNP establishes methods to assess and track the MODEL OF
CARE’s impact on the SNP beneficiaries’ health outcomes.
Describe, in detail, the processes and procedures the SNP will use to determine if the
health outcomes goals are met or not met.
Explain the specific steps the SNP will take if goals are not met in the expected time
frame.
C. Measuring Patient Experience of Care (SNP Member Satisfaction)
Describe the specific SNP survey(s) used and the rationale for selection of that particular
tool(s) to measure SNP beneficiary satisfaction.
Explain how the results of SNP member satisfaction surveys are integrated into the
overall MODEL OF CARE performance improvement plan, including specific steps to be
taken by the SNP to address issues identified in response to survey results.
D. Ongoing Performance Improvement Evaluation of the MODEL OF CARE
Explain, in detail, how the SNP will use the results of the quality performance indicators
and measures to support ongoing improvement of the MODEL OF CARE, including how
quality will be continuously assessed and evaluated.
Describe the SNP’s ability to improve, on a timely basis, mechanisms for interpreting and
responding to lessons learned through the MODEL OF CARE performance evaluation
process.
Describe how the performance improvement evaluation of the MODEL OF CARE will
be documented and shared with key stakeholders.
E. Dissemination of SNP Quality Performance related to the MODEL OF CARE
Explain, in detail, how the SNP communicates its quality improvement performance
results and other pertinent information to its multiple stakeholders, which may include,
but not be limited to: SNP leadership, SNP management groups, SNP boards of directors,
SNP personnel & staff, SNP provider networks, SNP beneficiaries and caregivers, the
general public, and regulatory agencies on a routine basis.
This description must include, but is not limited to, the scheduled frequency of
communications and the methods for ad hoc communication with the various
stakeholders, such as: a webpage for announcements; printed newsletters; bulletins; and
other announcement mechanisms.
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Identify the individual(s) responsible for communicating performance updates in a timely
manner as described in MODEL OF CARE Element 2A.
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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 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 state
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.
Note: 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 also complete and timely submit a separate SNP
Application. Existing SNPs that require re-approval under the NCQA SNP Approval
process should only submit their Model of Care (MOC) written narrative and MOC
Matrix Upload Document in the HPMS MOC Module. These SNPs will not be required
to submit any other portion of the MA application or SNP Application, 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) Applications 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 Application
unless the existing D-SNP is applying for a Service Area Expansion.
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2.5. Applicants Seeking to Expand Medicare Cost Plans
All 2020 applicants seeking to expand the service area of an existing Medicare Cost Plan
must complete and timely submit a Medicare Cost Plan SAE application. CMS will
continue to deny applications for Medicare Cost Plans expanding into areas where two or
more local or regional plans meeting minimum enrollment requirements exist in
accordance with 1876(h)(5)(C) of the SSA, 42 CFR 417.402(c), and CMS guidance.
2.6. Applicants Seeking to Serve Partial Counties
Applicants may request an exception to the county integrity rule at 42 CFR 422.2 by
attesting 'No' to Attestation 3.6.1 and uploading a Partial County Justification document
for each requested partial county in its service area. Applicants seeking to serve a partial
county must enter all service area information in HPMS by the application submission
deadline. Organizations requesting partial county service areas for the first time (initial or
SAE applicants) and organizations expanding a current partial county (SAE applicants)
by one or more zip codes (when the resulting service area will continue to be a partial
county) must submit their Partial County Justifications with their applications. 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. Similarly, applicants cannot expand a partial county
request to a full-county request during the application review period. Please note that
applicants expanding from a partial county to a full county do NOT need to submit a
Partial County Justification."
2.7.
Types of Applications
2.7.1. Initial 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 Organizations 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.
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
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Allocation of CMS payments between/among the member organizations.
2.7.2. Service Area Expansion Applications
Service Area Expansion applications are for:
Existing MAO contractors who are seeking to expand the service area of an existing
contract number.
Existing MAO contractors who are seeking to expand the service area of an existing
SNP.
Existing Medicare Cost Plans who are seeking to expand the service area of an
existing cost plan.
2.8. 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.
Table 0-1: Required Attestations by Type of Application
Attestation Section Name
Section #
Initial Applicants
Service Area Expansion
CCP
PFFS
RPPO
MSA
X
X
X
CCP
PFFS
RPPO
MSA
COST
Management, Experience, and History
3.1
X
Administrative Management
3.2
X
X
X
X
X
X
X
X
X
State Licensure
3.3
X
X
X
X
X
X
X
X
X
Program Integrity
3.4
X
X
X
X
Fiscal Soundness
3.5
X
X
X
X
X
X
X
X
Service Area
3.6
X
X*
X
X*
X
X*
X
X*
X
CMS Provider Participation Contracts
& Agreements
3.7
X
X
X
X
X
X
X
X
X
Contracts for Administrative &
Management Services
3.8
X
X
X
X
X
X
X
X
X
Quality Improvement Program
3.9
X
X
X
X
Marketing
Eligibility, Enrollment, and
Disenrollment,
3.10
X
X
X
X
X
X
X
X
Working Aged Membership
3.12
X
X
X
X
Claims
Communication between MAO and
CMS
3.13
X
X
X
X
X
X
X
X
Grievances
3.15
X
X
X
X
3.11
3.14
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Attestation Section Name
Organization Determination and
Appeals
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
Section #
3.16
3.17
Initial Applicants
Service Area Expansion
CCP
PFFS
RPPO
MSA
X
X
X
X
X
X
X
X
CCP
PFFS
RPPO
MSA
Continuation Area
3.18
X
X
X
X
X
X
X
X
Part C Application Certification
3.19
X
X
X
X
X
X
X
X
Access to Services
3.20
X
Claims Processing
3.21
X
X
X
X
Payment Provisions
3.22
X
X
X
X
General Administration/Management
3.23
Past Performance
3.24
X
X
X
X
X
X
*Applies to network PFFS and MSA applicants.
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X
X
X
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X
X
X
2.9. 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).
2.10. 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 2020 are provided in the Part D Application for MA-PD applicants
and must be followed. Failure to submit supporting documentation consistent with these
instructions may delay the review by CMS and may result in the applicant receiving a
NOID or a Notice of Denial.
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.
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3. ATTESTATIONS
3.1. Management, Experience, and History
The purpose of this section is to allow applicants to submit information describing
their organization's experience and organizational history, and the organization's
management structure. 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.
This section also ensures 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. Finally, this section ensures
that applicants (including but not limited to compliance officers, organization
employees, contractors, managers and directors) have a compliance plan and abide
by all Federal and State regulations, standards, and guidelines.
An organization must meet minimum enrollment requirements in order to
hold a Medicare Advantage contract with CMS (see 42 CFR 422.514). The
minimum enrollment requirement is an indicator that the organization applying for
a Medicare Advantage contract is able to handle risk and capitated payments. CMS
expects 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. CMS recognizes that new applicants may believe they are
capable of administering and managing an MA contract although they do not meet
the minimum enrollment requirements. CMS also recognizes that there may be
reasonable factors, such as specific populations served or geographic location that
might result in a plan having low enrollment. For example, SNPs may legitimately
have low enrollment because of their focus on a subset of enrollees with certain
medical conditions. Such organizations and new applicants may submit a request to
waive the enrollment requirements.
The following attestations were developed to implement the regulations of 42 CFR
422.502(b), 422.503(b) and 422.514.
A. In HPMS, complete the attestations and applicable uploads below:
MANAGEMENT, EXPERIENCE, AND HISTORY
YES
NO
3.1.1. Is the applicant applying to be the same type of
organization as indicated on the applicants NOIA?
The applicant may verify its organization type by
looking at the Contract Management Basic page. If
the type of organization the applicants organization
intends to offer has changed, do not complete this
application. Send an email by going to
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MANAGEMENT, EXPERIENCE, AND HISTORY
YES
NO
https://dmao.lmi.org/ and clicking on the MA
Applications tab. Please note: this is a webpage,
not an email address. Please indicate the pending
contract number and the type of organization for
which the applicant is now seeking to apply in the
email.
3.1.2. The applicant attests that it has at least 5,000
individuals enrolled for the purpose of receiving
health benefits from the organization; or it has at
least 1,500 individuals enrolled for purposes of
receiving health benefits from the organization and
the organization primarily serves individuals
residing outside of urbanized areas as defined in 42
CFR 412.62(f). The applicant may count members
enrolled in other risk based health insurance
products offered by the organization (e.g.,
commercial, Medicaid).
If the applicant attests "No," the applicant must
submit a Minimum Enrollment Waiver Request and
any supporting documentation.
Note: CMS will provide any Minimum Enrollment
Waiver review related deficiencies to applicants in
the Notice of Intent to Deny.
3.1.3. Applicant attests that it has completed the Contract
Management/ Information/ Data page in HPMS.
3.1.4. Applicant will adhere to all compliance regulations
in accordance with but not limited to 42 CFR
422.503(b)(4)(vi)
3.1.5
Applicant attests that the compliance officer
identified in the HPMS contacts is an employee of
the applicant, applicant’s parent organization, or a
corporate affiliate of the applicant in accordance
with 42 CFR §422.503(b)(4)(vi)(B)(1).
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 including ownership, subsidiaries, and business
affiliations.
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C. In HPMS, upload a Minimum Enrollment Waiver Request Upload Document and any
supporting documentation if you attested “No” to question 3.1.2.
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
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) and 422.506(a)(4)(a).
A. In HPMS, complete the attestations and applicable uploads below:
ADMINISTRATIVE MANAGEMENT
YES
NO
3.2.1. Applicant attests that it has a contract that non-renewed or
terminated a contract within the past two years as defined
under 42 CFR 422.506(a). The past two year period for this
application cycle would begin if the applicant non-renewed
or terminated after 12/31/2018. If the applicant only nonrenewed a demonstration Medicare-Medicaid Plan contract
after 12/31/2018, the applicant should attest N/A.
If the applicant attests "Yes," the applicant must upload a
Two Year Prohibition Waiver Request.
3.2.2. 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 and agrees to close
its Cost-Based Contract to new enrollment in any areas it is
approved to operate an MA product in accordance with 42
CFR 422.503(b)(4)(vi)(G)(5). If the applicant does not
currently operate a CMS Cost Contract under Section 1876
of the SSA in some or all of the intended service area of
this application, the applicant should respond “N/A”.
3.2.3. Applicant will adhere to all applicable Administrative
Management regulatory requirements including but not
limited to 42 CFR 422.503(b)(4).
B. In HPMS, upload the Two Year Prohibition Waiver Request Upload document if
you attested “Yes” to question 3.2.1.
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3.3. State Licensure
To ensure that all organizations operate in compliance with state and federal regulations,
CMS requires MAOs to be licensed under state law. This requirement will ensure that
organizations adhere to state regulations aimed at protecting Medicare beneficiaries. The
following attestations were developed based on the regulations at 42 CFR 422.400 and 42
CFR 417.404.
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 state that MA standards supersede State law or
regulation with respect to MA plans other than licensing laws and laws relating to plan
solvency.
A. In HPMS, complete the attestations and applicable uploads below:
STATE LICENSURE
YES
NO
3.3.1. Applicant attests that the organization is
incorporated and recognized by the state of
incorporation as of the initial application
submission deadline.
If the applicant attests "Yes," the applicant must
upload proof of the organization’s incorporation,
such as articles of incorporation or a certificate of
good standing from your state of incorporation.
Note: The applicant must be incorporated at
the time of the initial application deadline
submission. Not applicable for SAE applicants
3.3.2. Applicant is a Joint Enterprise.
If “Yes”, upload the copy of the Joint Enterprise
agreement executed by the State-licensed entities.
3.3.3. 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.
If “Yes,” upload in HPMS an executed copy of a
state licensing certificate and the CMS State
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STATE LICENSURE
YES
NO
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 applicants final
upload opportunity, which is in response to
CMS’ NOID communication.
Note: Joint Enterprise applicants must submit
state certification forms for each member of
the enterprise.
3.3.4. 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.
3.3.5. 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.
B. In HPMS, upload an executed copy of the State License Certificate and the CMS
State Certification Form for each state being requested, if you attested "Yes" to
question 3.3.1. If an SAE applicant is adding counties to an already approved MA
service area in a state, then only the CMS State Certification Form for that state needs
to be uploaded. The CMS State Certification Form must be current and must clearly
identify the requested service area. Forms related to prior years' application will not
be accepted.
C. In HPMS, upload a copy of the Joint Enterprise agreement executed by the statelicensed entities, if you attested “Yes” to the question 3.3.2.
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D. In HPMS, upload an 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 attested "Yes" to question 3.3.3.
E. In HPMS, upload the State Corrective Plans/State Monitoring Explanation (as
applicable), if you attested "Yes" to question 3.3.4.
F. In HPMS, upload the State Approval for d/b/a, if you attested “Yes” to question 3.3.5.
G. In HPMS, upload proof of the organization’s incorporation, such as articles of
incorporation or a certificate of good standing from your state of incorporation.
3.4. Program Integrity
A. In HPMS, complete the attestations and applicable uploads below:
PROGRAM INTEGRITY
YES
NO
3.4.1. 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. Fiscal Soundness
A. In HPMS, complete the attestations and applicable uploads below:
FISCAL SOUNDNESS
3.5.1
YES
NO
Applicant maintains a fiscally sound operation by at least
maintaining - a positive net worth (Total Assets exceed
Total Liabilities) in accordance with 42 CFR
422.504(a)(14).
B. Initial applicant only: In HPMS, upload:
1. The most recent audited annual financial statements that are available for
the legal entity (applicant); and
2. The most recent quarterly financial statements available for the legal entity
(applicant).
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Financial statements must include, at a minimum, a balance sheet, income statement, and
statement of cash flows. CMS reserves the right to request additional information, such as
a financial projections, as it sees fit to determine if the applicant is maintaining a fiscally
sound operation. In addition, CMS will verify that the applicant meets State financial
solvency requirements as documented on the CMS State Certification Form (uploaded
under State Licensure).
Note: If the applicant was not in business in previous years, 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
organization, it must submit the parent’s most recent audited financial
statements and the most recent Quarterly NAIC Health Blank or other form
of quarterly financial statement if the Quarterly Health Blank is not required
by your state.
C. SAE applicant only: CMS will confirm the attestation response by reviewing the
most recent audited annual financial statements submitted by the MAO through
the Fiscal Soundness Module in HPMS. If the most recent audited annual
financial statements in the HPMS fiscal soundness module do not demonstrate
that the applicant is maintaining a fiscally sound operation by at least maintaining
a positive net worth, the applicant must demonstrate that it is meeting fiscal
soundness requirements and upload either:
1. The final audited annual financial statements for the most recent fiscal
year end, demonstrating the organization is maintaining a fiscally sound
operation by at least maintaining a positive net worth (Total Assets exceed
Total Liabilities) in accordance with 42 CFR Section 422.504(a)(14), or
2. The most recent quarterly or annual financial statements and include an
opinion (such as a letter, not a full audit) from the applicant’s independent
auditor confirming that the organization’s most recent quarterly or annual
financial statements are meeting CMS’s fiscal soundness requirement by
at least maintaining a positive net worth (Total Assets exceed Total
Liabilities) in accordance with 42 CFR Section 422.504(a)(14).
3.6. Service Area
The purpose of the service area section is to clearly define which areas will be served by
the organization and 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, organizations 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.
A. In HPMS, complete the attestations and applicable uploads below:
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SERVICE AREA
YES
3.6.1. Applicant meets the county integrity rule in accordance with
42 CFR 422.2 and Chapter 4 of the MMCM (i.e., the
applicant has no partial counties in its service area).
If the applicant attests "No," the applicant must upload a Partial
County Justification document for each requested partial county in its
service area.
3.6.2. Applicant will adhere to all applicable regulatory
requirements including but not limited to 42 CFR 422.112,
422.500, 417.414, and 417.416, as well as sub-regulatory
guidance described in Chapter 4 of the MMCM.
3.6.3. 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 applicable geographic area.
3.6.4. Applicant attests that contracted providers and facilities meet
state and federal licensing requirements for the specialty type.
3.6.5. Applicant agrees that it will provide all medically necessary
transplant services to its Medicare enrollees in full agreement
with Chapter 4 of the MMCM. In addition, when providing
transplant services at clinical locations outside of the plan’s
service area, the applicant will arrange and pay for reasonable
accommodation and transportation for the enrollee/patient and
a companion.
3.6.6. Applicant agrees that it will provide all medically necessary
durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS), including access to providers qualified
to fit these devices, to its Medicare enrollees in full agreement
with Chapter 4 of the MMCM.
3.6.7. Applicant agrees that it will provide all medically necessary
Home Health Services to its Medicare enrollees in full
agreement with 42 CFR 422.112(a)(1)(i).
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NO
SERVICE AREA
YES
NO
3.6.8. Applicant attests that it will have a contracted network in
place that meets current CMS Medicare Advantage network
adequacy criteria for each county in its service area prior to
the start of the upcoming applicable contract year.
3.6.9. Applicant attests that it will monitor and maintain a
contracted network that meets current CMS Medicare
Advantage network adequacy criteria in accordance with 42
CFR 422.112(a)(1)
3.6.10. Applicant is an RPPO that has established networks in those
areas of the region where providers are available to contract
and will only operate 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 (see 42 CFR 422.2 and
422.112(a)(1)(ii)).
3.6.11. When using methods other than written contract agreements
to provide enrollees with access to all covered medical
services, including supplemental services contracted for by
(or on behalf of) the Medicare enrollee, the RPPO applicant
agrees to establish and maintain a process through which they
disclose to their enrollees in non-network areas
(Counties/specialties) how the enrollees can access plancovered medically necessary health care services from noncontracted providers at in-network cost sharing rates (see 42
CFR 422.111(b)(3)(ii) and 42 CFR 422.112(a)(1)(ii)).
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.
C. In HPMS, upload a Partial County Justification document(s) if you attested “No”
to question 3.6.1.
3.7. CMS Provider Participation Contracts & Agreements
This section contains attestations that address the requirements of 42 CFR 422.504 and
42 CFR 417.472, which require that organizations 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 organization is held responsible for the compliance of its providers and
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subcontractors with all contractual, legal, regulatory, and operational obligations.
Beneficiaries shall be protected from payment or fees that are the obligation of the
organization.
A. In HPMS, complete the attestations and applicable uploads below:
CMS PROVIDER CONTRACTS AND AGREEMENTS
YES
NO
3.7.1. Applicant will adhere to all applicable requirements of 42
CFR 422.504 and 42 CFR 417.472 including but not limited
to the following:
Applicant agrees to comply with all applicable
provider requirements in subpart E of this part,
including provider certification requirements, antidiscrimination 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).
Applicant agrees that all provider and supplier
contracts or agreements contain the required contract
provisions that are described in the Medicare Managed
Care Manual, and CMS regulations at 42 CFR
422.504.
Applicant has or will have executed provider, facility,
and supplier contracts in place to demonstrate
adequate access and availability of covered services,
in accordance with CMS established standards
throughout the requested service area.
Applicant agrees to have all provider contracts and/or
agreements available upon CMS request.
3.8. 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) and 42 CFR 417.412. Further guidance is provided in Chapter 11.
A. In HPMS, complete the attestations and applicable uploads below:
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CONTRACTS FOR ADMINISTRATIVE AND
MANAGEMENT SERVICES
3.8.1. Applicant has contracts with related entities, contractors and
subcontractors (first tier, downstream, and related entities) to
perform, implement or operate any aspect of operations for
the contract.
YES
NO
3.8.2. 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.
3.8.3. 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.
3.8.4. Applicant agrees that all contracts for administrative and
management services contain the required contract provisions
that are described in the MMCM, and the CMS contract
requirements in accordance with 42 CFR 422.504 and 42
CFR 417.412.
B. In HPMS, enter the Delegated Business Functions 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 applicants 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".
3.9. Quality Improvement Program
The purpose of this section is to ensure that all applicants have a Quality Improvement
Program (QI) Program. A QI Program 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.
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A. In HPMS, complete the attestations and applicable uploads below:
MAO/PPO/RPPO/LPPO Quality Improvement Program Plan
Requirements.
YES
NO
3.9.1. Applicant will adhere to all applicable QI Program regulatory
requirements at 42 CFR 422.152, as well as sub-regulatory
guidance described in Chapter 5 of the MMCM, including but
not limited to the following:
Applicant has an ongoing QI Program that can be
expected to have a favorable effect on health
outcomes and enrollee satisfaction;
Applicant agrees to provide CMS with all documents
pertaining to the QI Program upon request;
Applicant conducts a formal evaluation at least
annually, on the impact and effectiveness of the
MAOs overall quality improvement program.
3.10. 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 attestations and applicable uploads below:
MARKETING
YES
3.10.1. Applicant agrees to adhere to all marketing requirements in
422.2260 through 422.2276 and the Medicare Communications
and Marketing Guidelines.
3.10.2. Applicant agrees to provide beneficiaries with all required
documents found in 422.111 and the Medicare Communications
and Marketing Guidelines.
3.11. 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
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NO
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 attestations and applicable uploads below:
ELIGIBILITY, ENROLLMENT and DISENROLLMENT
YES
3.11.1. Applicant will adhere to all applicable Marketing related
regulations including but not limited to 42 CFR 422.50
through 422.74.
3.11.2. Applicant agrees to comply with eligibility, enrollment and
disenrollment procedures that are contained in Chapter 2 of
the MMCM
3.11.3. Applicant also agrees to comply with all CMS regulations
and guidance pertaining to eligibility, enrollment and
disenrollment for MA in MARx user guides, the annual Call
Letter, interim guidance and other communications
distributed via HPMS.
3.11.4. 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.
3.11.5. On a quarterly 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 CFR 422 subpart G.
3.12. 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.
A. In HPMS, complete the attestations and applicable uploads below:
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NO
WORKING AGED MEMBERSHIP
YES
NO
3.12.1. Applicant will adhere to all applicable regulatory
requirements including but not limited to 42 CFR 422.108,
including the following requirements: 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.
3.13. 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), 42 CFR 422.520(a) and 42 CFR 422.566 (a).
A. In HPMS, complete the attestations and applicable uploads below:
CLAIMS
YES
3.13.1. Applicant will be fully compliant with 42 CFR 422.504
(c), 42 CFR 422.520 (a) and 42 CFR 422.566 (a) and
agrees that upon receipt paper form or electronic submitted
claims will be date stamped, and will be processed
promptly in accordance with CMS regulations and
guidelines including:
Beneficiary receiving prompt denial or acceptance
notice of claim’s payment in a format consistent
with appeals and notice requirements stated in 42
CFR Part 422 Subpart M.
Having an effective system for receiving,
controlling, and promptly correcting and
processing claims
Establishing meaningful procedures to develop and
process all claims to comply with all applicable
standards and requirements
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NO
3.14. 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 attestations and applicable uploads below:
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COMMUNICATIONS between MAO and CMS
YES
3.14.1. 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.
3.14.2. 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.
3.14.3. Applicant agrees to establish connectivity to CMS via the
AT&T Medicare Data Communications Network (MDCN) or
via the Gentran Filesaver.
3.14.4. Applicant agrees to submit test enrollment and disenrollment
transmissions.
3.14.5. Applicant agrees to submit enrollment, disenrollment and
change transactions to CMS within 7 calendar days to
communicate membership information to CMS each month.
3.14.6. Applicant agrees to reconcile MA data to CMS
enrollment/payment reports within 45 days of availability.
3.14.7. Applicant agrees to submit enrollment/payment attestation
forms within 45 days of CMS report availability.
3.14.8. 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.
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NO
3.15. 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.
A. In HPMS, complete the attestations and applicable uploads below:
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GRIEVANCES
YES
NO
3.15.1. Applicant will be fully compliant with 42 CFR 422.561 and
42 CFR 422.564 in establishing meaningful processes,
procedures and effectively training relevant staff and
subcontractors (first tier, downstream and related entities) to
accept (by telephone and in writing (including fax) ), identify,
track, record, resolve and report enrollee grievances within
the established CMS guidelines including:
Having an accessible and auditable record of all oral
and written grievances received on behalf of the MAO
which maintain at a minimum: the receipt date,
submission mode (i.e., fax, telephone, letter, e-mail
etc.) the grievance originator (person or entity),
affected enrollee, subject, final disposition and date of
enrollee notification.
Advising all MA enrollees through the provision of
information and outreach materials of the definition of
a grievance, the complaint process that is available
under the Quality Improvement Organization (QIO),
their rights, the relevant process and associated
timelines for submission and resolution of grievances
to the MAO and its subcontractors (first tier,
downstream and related entities).
3.16. Organization Determination and 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
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 attestations and applicable uploads below:
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ORGANIZATION DETERMINATION and APPEALS
YES
3.16.1. Applicant will adhere to all applicable requirements of 42
CFR 422.561 including but not limited to the following:
Applicant agrees to adopt policies and procedures
for beneficiary organizational determinations,
exceptions, and appeals consistent with 42 CFR
422, subpart M.
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.
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.
Applicant agrees to ensure that the reconsideration
policy complies with CMS requirements as to
assigning the appropriate person or persons to
conduct requested reconsiderations.
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.
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NO
ORGANIZATION DETERMINATION and APPEALS
YES
NO
Applicant agrees to ensure that its reconsideration
policy complies with CMS required timelines
regarding applicants effectuation through payment,
service authorization or service provision in cases
where the organization’s determinations are
reserved in whole or part (by itself, the IRE, or some
higher level of appeal) in favor of the member.
Applicant agrees to make its enrollees aware of the
organization determination, reconsideration, and
appeals process through information provided in the
Evidence of Coverage and outreach materials.
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.
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
Applicant agrees to make available to CMS, upon
CMS request, organization determination and
reconsideration records.
Applicant agrees not to restrict the number of
reconsideration requests submitted by or on behalf
of a member.
3.17. Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
CMS issued guidance on 07/23/2007 and 8/28/2007; 2008 Call Letter
A. In HPMS, complete the attestations and applicable uploads below:
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HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996 (HIPAA)
1.
Applicant complies with the HIPAA administrative
simplification rules at 45 CFR Parts 160, 162, and 164.
2.
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”).
3.
Applicant agrees to submit the Offshore Subcontract
Information and Attestation for each offshore subcontractor
(first tier, downstream, and related entities) that receives,
processes, transfers, handles, stores, or accesses Medicare
beneficiary PHI by the last Friday in September for the
upcoming contract year.
4.
Applicant agrees to not use any part of an enrollee’s Social
Security Number (SSN) or Medicare ID Number on the
enrollee’s identification card.
YES
NO
3.18. 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 attestations and applicable uploads below:
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CONTINUATION AREA
YES
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).
NO
3.19. Part C Application Certification
A. In HPMS, upload a completed and signed pdf 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.
3.20. Access to Services (PFFS)
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, 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 2021 application
and contracting requirements can be found at:
http://www.cms.hhs.gov/PrivateFeeforServicePlans/. CMS will not accept a non-network
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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 attestations and applicable uploads below:
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ACCESS TO SERVICES PFFS
1.
2.
3.
4.
YES
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.
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.
Applicant agrees to offer a non-network PFFS model only
per 42 CFR 422.114(a)(2)(i).
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.
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NO
ACCESS TO SERVICES PFFS
5.
6.
YES
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)
• 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
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.
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.
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NO
ACCESS TO SERVICES PFFS
7.
YES
NO
Applicant agrees to provide information to its members and
providers explaining the provider deeming process and the
payment mechanisms for providers.
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
you selected "Other" for 3.22.5.
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)).
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.
3.21. Claims Processing (PFFS and 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 attestations and applicable uploads below:
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CLAIMS PROCESSING (PFFS and MSA)
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.
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.
4.
YES
Note: This attestation is not applicable to MSA Plans.
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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NO
3.22. Payment Provisions (PFFS and MSA)
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 attestations and applicable uploads below:
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PAYMENT PROVISIONS
1.
2.
3.
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).
Note: This attestation is not applicable to MSA applicants.
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)].
Note: This attestation is not applicable to MSA applicants
Applicant agrees that information in the Payment
Reimbursement Grid is true and accurate.
4.
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.
5.
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.
6.
The applicant has a system in place to ensure members are
not charged after the deductible has been met. [Refer to 42
CFR 422.103(c)].
7.
YES
Note: This attestation is not applicable to PFFS applicants.
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.
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NO
Note: Organization may use any format for the Payment Reimbursement grid
that best outlines the organization’s rates. There is no CMS-prescribed format.
3.23. General Administration/Management (MSA)
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 attestations and applicable uploads below:
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General Administration/Management (MSA)
1.
Applicant is offering a non-network MSA plan.
2.
Applicant is offering network MSA plans that follow the
CCP network model.
3.
Applicant is offering network MSA plans that follow the
PFFS network model.
4.
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.
5.
Applicant agrees to serve as the MA MSA Trustee or
Custodian for receiving Medicare deposits to MSA plan
enrollee accounts.
6.
Applicant will 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). Applicant will 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.
YES
NO
If applicant attests “Yes” the applicant must upload the executed
banking contract.
B. 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.
C. 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.
D. 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)).
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E. 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.
3.24. Past Performance
A. In HPMS, complete the attestations and applicable uploads below:
PAST PERFORMANCE
1.
YES
The Medicare Advantage plan(s) currently offered by the
applicant, applicants’ parent organization, or subsidiary of
the applicants’ parent organization has been operational
since January 1, 2020 or earlier. (If the applicant,
applicants parent organization, or a subsidiary of applicants
parent organization does not have any existing contracts
with CMS to operate a Medicare Advantage Plan, select
“NA”.)
Note: CMS will provide any Past Performance related
deficiencies to applicants in the Notice of Intent to
Deny.
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NO
Document Upload Templates
4.
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)
SECTION 1: All initial applicants, whether a new or existing organization, 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 ownership structure.
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 latest audited financial statement either
fiscal year or calendar year.
2.
What were the results of that audit?
3. Briefly describe the financial status of the applicants company.
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4.2. Minimum Enrollment Waiver Request Upload Document
Please complete and upload this document into HPMS per the HPMS MA Application User
Guide instructions.
Applicant’s Contract Name (as provided in HPMS): ___________________________
Applicant’s CMS Contract Number:_______________________________________
1.
a) Does the contract applicant (organization) have previous experience in
managing and providing health care services under a risk-based payment
arrangement to at least as many individuals as the applicable minimum enrollment
for the entity as described in 42 CFR §422.514? (yes/no).
b) If response in 1(a) is yes, please describe the extent of this experience.
2. a) Does the contract applicant’s parent organization have previous experience in
managing and providing health care services under a risk-based payment
arrangement to at least as many individuals as the applicable minimum enrollment
for the entity as described in 42 CFR §422.514? (yes/no).
b) If response in 2(a) is yes, please describe the extent of this experience.
3. a) Does the contract applicant’s management and providers have previous
experience in managing and providing health care services under a risk-based
payment arrangement to at least as many individuals as the applicable minimum
enrollment for the entity as described in 42 CFR §422.514? (yes/no).
b) If response in 3(a) is yes, please describe the extent of this experience.
4. a) Does the applicant have stop-loss insurance? (yes/no)
b) If response in 4(a) is yes, please provide evidence of this stop-loss insurance.
5. Please describe any factors, such as specific populations your organization
intends to serve or geographic locations, which may result in low enrollment?
6. Please describe how your organization is able to establish a marketing and
enrollment process that allows your organization to meet the applicable minimum
enrollment requirements specified in 42 CFR §422.514.
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4.3. Two Year Prohibition Waiver Request Upload Document
Please complete and upload this document into HPMS per the HPMS MA Application User
Guide instructions.
Applicant’s Contract Name (as provided in HPMS): ___________________________
Applicant’s CMS Contract Number:_______________________________________
Date of Contract Non-Renewal:____________________________________
Under 42 CFR 422.506(a)(4)(a) CMS will not enter into a contract with a Medicare
Advantage (MA) Organization for 2 years unless there are special circumstances
that warrant special consideration as determined by CMS. If organization attests
“yes” to attestation #1 under Administrative Management the MA Organization is
required to submit the Two Year Prohibition Waiver Request Upload Document for
review and consideration by CMS. The MA organization should provide a
description of the circumstance that warrant special consideration related to the
non-renewal of your MA contract. The past 2 year period for this application cycle
would begin if the MAO non-renewed or terminated after 12/31/2018.
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4.4. 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 - 4), then forward the document to
the appropriate State Agency Official who should complete those items below the line
(items 5-8). 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. The completed form must be
current and must include the requested service area. Forms submitted for prior years’
applications will not be accepted. 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.
Note: The NAIC number must be populated within the Contract Management
Module in HPMS.
Items 1 - 4 (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.
4. Enter the National Association of Insurance Commissioners (NAIC) number
if there is one.
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.
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Items 5 - 8 (to be completed by State Official):
5. List the reviewer’s pertinent information in the event CMS needs to
communicate with the individual conducting the review at the State level.
6. List the requested information regarding other State departments/agencies
required to review requests for licensure.
7. 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.
8. 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.
MEDICARE ADVANTAGE (MA)
STATE CERTIFICATION REQUEST
MA applicants should complete items 1-4.
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 ________
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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:
_______________________________________________________________
4. National Association of Insurance Commissioners (NAIC) number:
____________
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 5-8)
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.
5. State official reviewing MA State Certification Request:
Reviewer’s Name
_______________________________________________________________
State Oversight/Compliance Officer
_______________________________________________________________
Agency Name
_______________________________________________________________
Address
_______________________________________________________________
Address
_______________________________________________________________
City/State
_______________________________________________________________
Telephone
_______________________________________________________________
_
E-Mail Address
_______________________________________________________________
6. Name of other State agencies (if any) whose approval is required for
licensure:
Agency______________________________________________
Contact Person________________________________________
Address______________________________________________
City/State____________________________________________
Telephone____________________________________________
E-Mail Address _______________________________________
7. Financial Solvency:
Does the applicant organization named in item 1 above meet State financial
solvency requirements? (Please circle the correct response)
● Yes ● No
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Please indicate which State Agency or Division is responsible for assessing
whether the named applicant organization meets State financial solvency
requirements.
_______________________________________________________________
8. 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
______________________________
Date
______________________________
Signature
_____________________________
Title
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4.5.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, is Medicare-approved, 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 applicants 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.
Authorized Representative Name (printed)
Title
Authorized Representative Signature
Date (MM/DD/YYYY)
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4.6.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
If No, Give
Date
Application
was Filed
with State
2021 Part C Application
Type of License
Held or
Requested
Does State have
Restricted
Reserve
Requirements (or
Legal
Equivalent)? If
Yes, Give
Amount
FINAL
State Regulator’s
Name, Address
Phone #
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4.7.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 applicants 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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4.8.Partial County Justification
Instructions: Organizations requesting service areas that include one or more partial counties must
upload a completed Partial County Justification
Complete and upload a Partial County Justification form for each partial county in your service area.
Organizations expanding from a partial county to a full county do NOT need to submit a Partial County
Justification.
If an organization would like to request a Network Exception Request for a partial county, the
organization must do so during its network adequacy review in the Network Management Module and
must use the same process available to organizations operating in the full county.
Note: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
Using just a few sentences, briefly describe the reason for your partial county, and complete the
following to reflect your situation:
Request for new partial county: Zip Code(s)______________________
Request to expand current partial county by 1+ zip code(s): Zip Code(s)__________________
Previously approved/current partial county
Year Approved______________
Zip Code(s)________________________
SECTION II: Partial County Requirements
The Medicare Managed Care Manual Chapter 4, Section 140.3 provides guidance on partial county
requirements. The following questions pertain to those requirements; refer to Section 140.3 when
responding to them.
Explain how and submit documentation to show that the partial county meets all three of the following
criteria:
1. Necessary – It is not possible to establish a network of providers to serve the entire county.
Describe the evidence that you are providing to substantiate the above statement that it is not
possible to establish a network to serve the entire county and (if applicable) attach it to this form:
2. Non-discriminatory – You must be able to substantiate both of the following statements:
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.
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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.
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5.
APPENDIX I: Special Needs Plan (SNP) Application
5.1 Overview
The Bipartisan Budget Act of 2018 (BBA of 2018) permanently authorized special needs
plans (SNPs), including dual eligible special needs plans (D-SNPs), chronic condition
SNPs (C-SNP), and institutional SNPs (I-SNP). 42 CFR 422.2 defines special needs
individuals and SNPs for special needs individuals.
The BBA of 2018 also requires the establishment of new standards for integration of
Medicare and Medicaid benefits provided to enrollees in D-SNPs, as well as the
development unified appeals and grievance processes for D-SNPs, beginning in CY
2021. CMS-4185-F, “Medicare and Medicaid Programs; Policy and Technical Changes
to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of AllInclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid
Managed Care Programs for Years 2020 and 2021,” published in the Federal Register on
April 16, 2019, modified and amended 42 CFR 422 to codify integration criteria for all
D-SNPs and unified appeals and grievance processes for some D-SNPs (those defined as
“applicable integrated plans”) beginning in CY 2021.
SNPs are required to follow existing MA and Prescription Drug Benefit program rules. .
An applicant intending to offer a SNP must be qualified under the MA and Part D
application in all counties of the SNP type service area. Therefore, an applicant may need
to submit an MA and Part D application in conjunction with its SNP application. The
timeline for submitting a SNP application is the same as the MA application timeline.
Please see the section below for more information.
Applicants must complete the 2021 SNP application within HPMS as instructed. CMS
will only accept submissions using this current 2021 version of the SNP application. All
uploaded documentation must contain the appropriate CMS-issued contract number.
In preparing a response to the prompts throughout this application, the applicant must
attest “Yes” or “No.” In some instances, applicants will have the opportunity to attest
“N/A” if the attestation does not apply. Applicants must upload various documents in
HPMS. SNP application upload documents are described throughout the SNP attestation
sections. The applicant should read the sections carefully in order to provide the
information as requested.
CMS strongly encourages SNP 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. Applicants should read HPMS
memos and visit the CMS web site periodically to stay informed about new or revised
guidance documents.
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For further guidance regarding SNPs. refer to Chapter 16b: Special Needs Plans of the
MMCM.
5.2
SNP Application Types
All applicants must submit their SNP Application by completing the HPMS SNP
Application template and submitting all completed upload documents per the HPMS User
Guide instructions. A SNP application must be completed for each SNP type to be
offered by the MA organization.
A D-SNP must have a State Medicaid Agency Contract in place prior to the beginning of
the 2021 contract year, which aligns with the entire 2021 SNP contract term.
5.2.1 Initial (New) SNP Applications
Initial (new) SNP applications are for:
New applicants or existing MA organizations seeking to offer a SNP for the first
time. Note: An initial applicant seeking to offer a SNP must submit an MA and
Part D application in conjunction with the SNP Application.
Existing MA organizations seeking to offer a new SNP type that they do not currently
offer. Note: The applicant or the existing MA organization must be qualified
under the MA and Part D application in all counties of the SNP type service
area.
Note: If the MA service area is not approved due to unresolved deficiencies, the new
SNP or SNP SAE Application will not be approved.
5.2.2. SNP Service Area Expansion Applications
SNP Service Area Expansion Applications are for:
An MA organization currently offering a SNP that wants to expand the service
area of the SNP. Even if the SNP is the only plan benefit package in a contract,
the MA organization must complete in HPMS the MA-PD SAE (to trigger the
SNP SAE) and the SNP SAE for the overall MA contract.
Note: For contract year 2021, all D-SNPs, including D-SNPs seeking to
expand their service area, must submit a new State Medicaid Agency
Contract or a current (evergreen) contract with amendments and submit the
applicable D-SNP attestations and required uploads in order to meet the new
D-SNP requirements as a result of the BBA of 2018 which amended section
1859 of the Social Security Act and updated requirements in 42 CFR 422.
For contract year 2021 only, evergreen contracts with letters of good
standing will not be accepted for purposes of the D-SNP State Medicaid
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Agency Contract review. A State Medicaid Agency Contract that reflects
requirements effective CY 2021 is required.
Note: The service area of the proposed SNP cannot exceed the existing or
pending service area for the MA contract.
Note: If the MA service area is not approved due to unresolved deficiencies, the new
SNP or SNP SAE Application will not be approved.
Note: The MOC Matrix Upload Document and the MOC Narrative are not required
with the SAE application.
5.3
Renewal SNPs that are Not Expanding their Service Area:
An MA organization currently offering a SNP that requires re-approval under the
National Committee for Quality Assurance (NCQA) SNP Approval process should
submit its MOC written narrative and MOC Matrix Upload Document in the HPMS
MOC Module, and will not be required to submit any other portion of the MA application
or SNP Application, 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 MA application or SNP
Application unless specifically noted (e.g., to meet the requirement for contracting with a
State Medicaid Agency).
Note: For contract year 2021, all D-SNPs, including renewal D-SNPs that are not
expanding their service area, must submit a new State Medicaid Agency Contract or
a current (evergreen) contract with amendments and submit the applicable D-SNP
attestations and required uploads in order to meet the new D-SNP requirements as
a result of the BBA of 2018, which amended section 1859 of the Social Security Act
and resulted in updated requirements in 42 CFR 422. For contract year 2021 only,
evergreen contracts with letters of good standing will not be accepted for purposes
of the D-SNP State Medicaid Agency Contract review.
The Affordable Care Act amended section 1859(f) of the Social Security Act to require
that all SNPs be approved by NCQA starting January 1, 2012, and subsequent years. 42
CFR §§ 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 MOC as per CMS guidance.
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5.4 D-SNP State Medicaid Agency(ies) Contract(s): Attestation and Uploads
State Medicaid Agency Contracts- Note that these attestations and uploads
should not be submitted with the Part C Application in February 2020. CMS
will send HPMS memo indicating when the SMAC module will be available
for uploads. The SMAC documents will be due by July 6, 2020.
Attestation
1. Applicant has an existing, executed contract(s) with the
State Medicaid Agency in the state(s) in which the applicant
seeks to operate for the MA application year by July 6,
2020.
Response
Note: Applicants for dual-eligible SNPs (initial, existing,
and existing/expanding) must have a signed State Medicaid
Yes/No
Agency(ies) Contract by the CMS specified deadline. A
current (evergreen) contract with amendments, or future
contract, must be uploaded each application cycle or year.
For contract year 2021, submission of only evergreen
contracts with letters of good standing will not be accepted.
Note: This attestation and upload should be completed in
the SMAC module at the time of the SMAC submission.
2. Applicant’s contract with the State Medicaid Agency(ies)
qualifies as a highly integrated dual eligible SNP (HIDE
SNP). Note: Please refer to Section 5.12 to help make
this determination.
If the applicant attests “Yes,” upload the completed D-SNP
State Medicaid Agency Contract Matrix and SNP Status
Contract Matrix with your SMAC before July 6, 2020.
Yes/No
NOTE: This attestation and upload should be completed in
the SMAC module at the time of the SMAC submission.
3. Applicant’s contract with the State Medicaid Agency(ies)
qualifies as a fully integrated dual eligible SNP (FIDE SNP).
Note: Please refer to Section 5.12 to help make this
determination.
Yes/No
If the applicant attests "Yes," upload the completed D-SNP
State Medicaid Agency Contract Matrix and SNP Status
Contract Matrix with your State Medicaid Agency Contract
before July 6, 2020.
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Attestation
Response
Note: This attestation and upload should be completed in
the SMAC module at the time of the SMAC submission.
4. Applicant has a contract with the State Medicaid
Agency(ies) that stipulates that the SNP notifies, or arranges
for another entity or entities to notify, the State Medicaid
Agency and/or its designee(s) of hospital and skilled nursing
facility admissions for at least one group of high-risk fullbenefit dual eligible individuals identified by the State
Medicaid Agency.
If the applicant attests “Yes,” upload the completed D-SNP
State Medicaid Agency Contract Matrix (see Section 5.11)
before July 6, 2020
Yes/No
NOTE: This attestation and upload should be completed in
the SMAC module at the time of the SMAC submission.
NOTE: If Applicant attested “No” to attestations 2 and 3
in this table, it must attest “Yes” to this attestation.
5. Consistent with the definition of a SNP with exclusively
aligned enrollment at 422.2, Applicant is a SNP that
exclusively enrolls full-benefit dual eligible individuals
whose Medicaid benefits are covered under a Medicaid
managed care organization contract under section 1903(m)
of the Act between the applicable State and the SNP’s MA
organization, the SNP’s parent organization, or another
entity that is owned and controlled by the D-SNP’s parent
organization.
Yes/No
NOTE: If the applicant attests “Yes,” and is a FIDE SNP
or HIDE SNP, per the responses to attestations 3 and 4 of
this section, then the applicant agrees to use the unified
appeals and grievance procedures under 422.629 through
422.634, 438.210, 438.400 and 438.402 and must complete
the SNP Status Contract Matrix elements 1 and 2.
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5.5. I-SNP: Attestations and Uploads
Attestation
Response
I-SNP Individuals Residing ONLY in Institutions
1. Applicant will only enroll institutionalized
individuals residing in a long-term care (LTC)
facility under contract with or owned and operated
by the SNP.
Yes/No
Corresponding Upload Document:
I-SNP residing Only in Institutions.
Attestation
Response
I-SNP Individuals Residing ONLY in the Community
1. Applicant will enroll only individuals who are
institutional equivalents residing in the
community.
Corresponding Upload Documents:
Yes/No
I-SNP residing Only in Community, and
A Copy of the respective State’s Level of Care
(LOC) assessment tool to determine eligibility
for each institutional equivalent beneficiary.
Attestation
Response
I-SNP Individuals Residing in BOTH Institutions and the Community
1. Applicant will enroll individuals who are
both institutionalized and institutionalized
equivalents residing in the community.
Corresponding Upload Documents:
SNP Individuals Residing in Both
Institutions and the Community, and
A Copy of the respective State’s Level of
Care (LOC) assessment tool to determine
eligibility for each institutional equivalent
beneficiary.
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5.6. C-SNP, D-SNP and I-SNP ESRD Waiver Request: Attestation and
Upload
Attestation
1. Applicant is applying to offer a new SNP targeting
individuals having ESRD.
If applicant answered "Yes," download the SNP ESRD
Waiver Request Upload Document, fully complete it, and
upload the completed document.
Response
Yes/No
5.7. MOC: Attestation and Uploads
Attestation
1. Applicant has submitted a written description of its
MOC as defined in the MOC Matrix upload document.
Upload a copy of the written MOC AND Download the
MOC Matrix Upload Document, fully complete it, and
upload the completed document
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Response
Yes/No
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5.8 Health Risk Assessment: Attestations
Attestation
Response
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 which includes some or all of the following:
a. conduct an initial comprehensive health risk assessment
within 90 days of enrollment and use the results to develop the Yes/No
individualized care plan for each beneficiary
b. conduct annual comprehensive health risk assessment and
the results are used to update the individualized care plan for Yes/No
each beneficiary
c. comprehensive initial and annual health risk assessment
examines covers medical, psychosocial, cognitive, and
Yes/No
functional status
d. comprehensive health risk assessment is conducted face-toYes/No
face by the applicant
e. comprehensive health risk assessment is conducted
Yes/No
telephonically by the applicant
f. comprehensive health risk assessment is conducted by
having the beneficiary complete an electronic or paper-based Yes/No
questionnaire
2. Applicant develops or selects and utilizes a comprehensive risk assessment tool
that will be reviewed during oversight activities and consists of:
a. an existing validated health risk assessment tool
Yes/No
b. a plan-developed health risk assessment tool
Yes/No
c. an electronic health risk assessment tool
Yes/No
d. a paper health risk assessment tool
Yes/No
e. uses a standardized health risk assessment tool for all
Yes/No
beneficiaries
f. periodically reviews the effectiveness of the health risk
Yes/No
assessment tool
3. Applicant has a process to conduct authoritative health risk assessment, analyze
identified health risks, and stratify them to develop an individualized care plan that
mitigates health risks through some of the following methods:
a. Comprehensive health risk analysis is conducted by a
Yes/No
credentialed healthcare professional
b. Applicant notifies the Interdisciplinary Care Team,
respective providers, and beneficiary about the results of the Yes/No
health risk analysis
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Attestation
c. Applicant tracks and trends population health risk data to
inform the development of specialized benefits and services
d. Applicant uses predictive modeling or other software to
stratify beneficiary health risks for the development of an
individualized care plan
e. Applicant manually analyzes health risk data to stratify
beneficiary health risks for the development of an
individualized care plan
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Response
Yes/No
Yes/No
Yes/No
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5.9. SNP Quality Improvement Program: Attestations
Attestation
1. Applicant has a written plan including policies,
procedures, and a systematic methodology to conduct an
overall quality improvement program that is specific to its
targeted special needs individuals. 42 CFR §152(g)
2. Applicant conducts an annual review of the effectiveness
of its quality improvement program.
3. For each special needs plan, applicant collects, analyzes,
and reports data that measure health outcomes and indices
of quality pertaining to the management of care for its
targeted special needs population (i.e., dual-eligible,
institutionalized, or chronic condition) at the plan level.
4. 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).
5. 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).
6. For each special needs plan, applicant collects, analyzes,
and reports data that measure staff implementation of the
SNP MOC (e.g., National Committee for Quality
Assurance accreditation measures or medication
reconciliation associated with care setting transitions
indicators).
7. 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).
8. For each special needs plan, applicant collects, analyze,
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).
9. 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.)
10. 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
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Response
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
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Attestation
Response
vulnerable beneficiaries (frail, disabled, near the end-oflife, etc.).
11. For each special needs plan, applicant collects, analyzes,
and reports data that measure provider use of evidencebased practices and/or nationally recognized clinical
protocols.
12. 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.).
13. 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.
14. 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.
15. For each special needs plan, applicant collects, analyzes,
and reports CMS-required Medication Therapy
Management measures that will enable CMS to monitor
plan performance.
16. For each special needs plan, applicant can demonstrate it
has a provider network having targeted clinical expertise
as evidenced by measures from medication management,
disease management, or behavioral health domains.
17. For each special needs plan, applicants agrees to
disseminate the results of the transitions of care analysis to
the interdisciplinary care team.
18. Applicant can provide CMS with documentation on
policies and procedures that will enable CMS to monitor
the plans MOC performance.
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Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
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5.10. Past Performance Attestation
Attestation
Response
1. 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, 2020 or earlier. (If the
Yes/No
applicant, applicants parent organization, or a subsidiary
of applicants parent organization does not have any
existing contracts with CMS to operate a Medicare
Advantage Plan, select “NA”.)
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5.11 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 items that may have been part of previously signed contracts that are still
effective due to it being a multi-year contract, in addition to any items below that are part
of a new amendment. When designating the page numbers and sections below, please
note if the page numbers and sections are in an amendment to the SMAC. If an element is
not applicable, please indicate that in the not applicable column.
STATE CONTRACT REQUIREMENTS
Plan Name:_________________
PBP:_______________________
Date:_______________________
State:_______________________
Contract Provision
Page
Number(s)
1. How the SNP coordinates the delivery of Medicaid
benefits for individuals who are eligible for such
services. This includes Medicaid services covered
under Medicaid fee-for-service, by the SNP’s MA
organization, the SNP itself (or a Medicaid plan
offered by the SNP’s parent organization or another
entity owned and controlled by its parent
organization), or by other Medicaid plans available in
the state. (422.107(c)(1)(i))
NOTE: Page number and section number must be
completed by all D-SNPs.
2. If applicable, how the SNP provides coverage of
Medicaid services, including long-term services and
supports and behavioral health services, for
individuals eligible for such services.
(422.107(c)(1)(ii))
NOTE: Page number and section number should
be completed by applicable D-SNPs; however, if
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Section
Number
Not
Applicable
Contract Provision
Page
Number(s)
not applicable, D-SNP should indicate that in the
not applicable column.
3. The category(ies) and criteria for eligibility for dual
eligible individuals to be enrolled under the SNP,
including as described in sections 1902(a), 1902(f),
1902(p), and 1905 of the Act. (422.107(c)(2))
NOTE: If applicable, please use State aid codes to
identify category of duals being enrolled. Page
number and section number must be completed by
all D-SNPs.
4. Medicaid benefits covered under a capitated contract
between the State Medicaid Agency and the MA
organization offering the SNP, the SNP’s parent
organization, or another entity that is owned and
controlled by the SNP’s parent organization.
(422.107(c)(3))
NOTE: Page number and section number should
be completed by applicable D-SNPs; however, if
not applicable please indicate that in the not
applicable column.
Please provide specific page numbers and section
numbers for:
Medicaid behavioral health services,
Medicaid long-term supports and services,
Medicaid payment of Medicare cost sharing,
and
Other Medicaid benefits
For the bulleted items above, if D-SNPs are not
capitated to provide the specific Medicaid service they
should indicate that in the not applicable column.
5. Language that identifies the entity (your MA
organization, parent organization, or other
organization owned and controlled by your parent
organization) that holds the capitated contract with the
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Section
Number
Not
Applicable
Contract Provision
Page
Number(s)
Section
Number
Not
Applicable
State Medicaid Agency for the Medicaid benefits
covered. (422.107(c)(3))
NOTE: Page number and section number must be
completed by all D-SNPs. However, if not
applicable please enter that in the not applicable
column.
6. Cost-sharing protections covered under the SNP.
(422.107(c)(4))
NOTE: Page number and section number must be
completed by all D-SNPs.
7. Identification and sharing of information on Medicaid
provider participation. (422.107(c)(5))
NOTE: Page number and section number must be
completed by all D-SNPs.
8. Verification of enrollee’s eligibility for both Medicare
and Medicaid. (422.107(c)(6))
NOTE: Page number and section number must be
completed by all D-SNPs.
9. Service area covered by the SNP. (422.107(c)(7))
NOTE: Page number and section number must be
completed by all D-SNPs.
10. The contract period for the SNP. (422.107(c)(8))
NOTE: Page number and section number must be
completed by all D-SNPs.
If you answered “Yes” to attestation 4 in section 5.4, or if your SNP is seeking HIDE or FIDE
designations and meets some or all of the following provisions, please also identify the page number
and section number for those provisions if the information is in the SMAC. Otherwise, if it is not
applicable please indicate that in the not applicable column.
11. Criteria for identification of the group of high-risk
full-benefit dual eligible individuals identified by the
State Medicaid Agency for which notification of
hospital and skilled nursing facility admissions will
apply. (422.107(d))
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Contract Provision
Page
Number(s)
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
12. Language that indicates the entity (your organization
or the type of entity or entities) responsible for
providing the notification of hospital or skilled nursing
facility admissions. (422.107(d))
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
13. Language that indicates the entity or entities (the State
Medicaid Agency, or the State’s designee(s))
responsible for receiving notifications of hospital and
skilled nursing facility admissions. (422.107(d))
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
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Section
Number
Not
Applicable
Contract Provision
Page
Number(s)
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
14. If your organization designates another entity(ies) to
provide the notification on your behalf, language that
indicates that your organization retains responsibility
for complying with the notification requirement.
(422.107(d))
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
15. The timeframe that your organization or your designee
has to provide notification of hospital and skilled
nursing facility admissions to the State Medicaid
Agency or its designee(s). (422.107(d))
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
16. The method(s) your organization or your designee
uses to provide notification of hospital and skilled
nursing facility admissions to the State Medicaid
Agency or its designee(s). (422.107(d))
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Section
Number
Not
Applicable
Contract Provision
Page
Number(s)
Section
Number
NOTE:
Page number and section number must be
completed for organizations that answered
“Yes” to attestation 4 in section 5.4.
Organizations seeking HIDE or FIDE SNP
designation should complete the page
number and section number if language is
included in SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
5.12 Special Needs Plan (SNP) Contract Status Review Matrix
Plans should use this document to identify where each SNP element is met within
their contract(s). The matrix will be used to assist the Centers for Medicare &
Medicaid Services (CMS) in conducting the HIDE and FIDE SNP determination
reviews. If an element is not applicable, please indicate that in the not applicable
column.
NOTE: To be designated as a HIDE SNP, a D-SNP must identify contract language
for provision 3 and provisions 5 or 6. To be designated as a FIDE SNP, a D-SNP
must provide contract language for provisions 3-9. Please answer all questions. If an
element is not applicable please indicate that in the not applicable column.
If the applicant is seeking HIDE or FIDE designation, then the following matrix
must be completed.
It is optional for organizations that answered “Yes” to attestation 4 in section 5.4,
stipulating that the SNP notifies, or arranges for another entity or entities to notify,
the State Medicaid Agency and/or its designee(s) of hospital and skilled nursing
facility admissions for at least one group of high-risk full-benefit dual eligible
individuals identified by the State Medicaid Agency, to complete this table.
SPECIAL NEEDS PLAN (SNP) CONTRACT STATUS REVIEW MATRIX
Plan Name:_________________
PBP:_______________________
Date:_______________________
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Not
Applicable
State:_______________________
Coverage: LTC____
BH____ Both____
Page
Section
Not
Number(s) Number Applicable
1. If applicable based on state policy, language that indicates
your organization has exclusively aligned enrollment,
meaning that it only enrolls full-benefit dual eligible
individuals whose Medicaid benefits are covered under a
Medicaid managed care organization contract under
section 1903(m) of the Social Security Act between the
applicable State and your organization, parent organization
or another entity that is owned and controlled by your
organization’s parent organization. (422.2)
NOTE: All D-SNPs completing this table must
complete this row. The page number and section
number must be completed for organizations that
answered “Yes” to attestation 5 in section 5.4.
Otherwise if not applicable please indicate that in the
not applicable column.
2. If applicable based on exclusively aligned enrollment
attestation above, language that describes how your
organization uses the unified appeals and grievance
procedures under 422.629 through 422.634, 438.210,
438.400 and 438.402. (422.107(c)(9))
NOTE: All D-SNPs completing this table must
complete this row. The page number and section
number must be completed for organizations that
answered “Yes” to attestation 5 in section 5.4.
Otherwise if not applicable please indicate that in the
not applicable column.
3. Language that identifies the entity (your MA organization,
parent organization or other organization owned and
controlled by your parent organization) that holds the
capitated contract with the State Medicaid Agency. (422.2)
NOTE: Page number and section number must be
completed for organizations seeking HIDE or FIDE
SNP designations.
For FIDE SNP status only, the same legal entity
must hold both the MA contract with CMS and
the Medicaid managed care organization (as
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defined in 438.2) contract with the applicable
state.
For HIDE SNP status, the legal entity that holds
the MA contract with CMS and the legal entity
that holds the Medicaid managed care contract
can be the MA organization, the parent
organization, or other organization owned and
controlled by your parent organization.
4. Language that indicates that your organization has a
capitated contract with the State Medicaid Agency that
provides coverage, consistent with State policy, of primary
and acute care. (422.2)
NOTE:
Page number and section number must only be
completed for organizations seeking a FIDE
SNP designation.
Other organizations should complete the page
number and section number if language is
included in the SMAC. Otherwise if it is not
applicable please indicate this in the not
applicable column.
5. Language that indicates that your organization has a
capitated contract with the State Medicaid Agency that
provides coverage, consistent with State policy, of
behavioral health services. (422.2)
NOTE: Page number and section number must be
completed for organizations seeking HIDE or FIDE
SNP designations.
For HIDE SNPs, element 5 OR element 6 must
be completed.
For FIDE SNP status, coverage of behavioral
health services is not required when it is not
consistent with state policy (i.e., Medicaid
behavioral health is covered by the State
through Medicaid Fee-for-service).
6. Language that indicates that your organization has a
capitated contract with the State Medicaid Agency that
provides coverage, consistent with State policy, of longterm services and supports, including in community-based
settings. (422.2)
NOTE: Page number and section number must be
completed for organizations seeking HIDE or FIDE
SNP designations.
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For HIDE SNP status, element 5 OR element 6
must be completed.
7. Language that indicates that your organization has a
capitated contract with the State Medicaid Agency that
provides coverage, consistent with State policy, of nursing
facility services for a period of at least 180 days during the
plan year. (422.2)
NOTE:
Page number and section number must only be
completed for FIDE SNP designation.
Other organizations should complete the page
number and section number if language is
included in the SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
8. Language that describes how your organization
coordinates the delivery of covered Medicare and
Medicaid services using aligned care management and
specialty care network methods for high-risk beneficiaries.
(422.2)
NOTE:
Page number and section number must only be
completed for FIDE SNP designation.
Other organizations should complete the page
number and section number if language is
included in the SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
9. Language that indicates that your organization employs
policies and procedures approved by CMS and the State to
coordinate or integrate beneficiary communication
materials, enrollment, communications, grievance and
appeals, and quality improvement. (422.2)
NOTE:
Page number and section number must only be
completed for FIDE SNP designation.
Other organizations should complete the page
number and section number if language is
included in the SMAC. Otherwise if it is not
applicable please indicate that in the not
applicable column.
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5.13 I-SNP Upload Documents
5.13.1 I-SNP Individuals Residing Only in Institutions
Please complete and upload this document into HPMS per the HPMS MA
Application User Guide instructions.
I-SNP Individuals Residing Only in Institutions Upload Document
Applicants Contract Name (as provided in HPMS):_______________________
CMS Contract Number:_________________________________
1. Provide a list of contracted long-term care facilities. (Provide the Names and
addresses of the Contracted Long-term Care facilities)
2. 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 and operated 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
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community setting to ensure beneficiaries will be assessed and receive services as required under
the SNP Model of Care.
Authorized Representative Name (Print):________________________________
Authorized Representative Signature:____________________________________
Title:______________________________________________________________
Date:_______________________________________________________________
5.13.2. I-SNP Individuals Residing Only in the Community
Please complete and upload this document into HPMS per the HPMS MA Application User
Guide instructions.
I-SNP Individuals Residing Only in the Community Upload Document
Applicants Contract Name (as provided in HPMS):_______________________
CMS Contract Number:_________________________________
1.
Provide the name of the entity(ies) performing the level of care (LOC)
assessment for enrolling individuals living in the community.
2.
Provide the address of the entity(ies) performing the LOC assessment.
3.
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.
4.
Provide a list of assisted-living facilities (if applicant is contracting with
ALFs at the time of application)
5.
Provide attestation for I-SNP serving individuals residing ONLY in the
Community. (Provide the names and addresses of the assisted living
facilities)
Attestation for Institutional Equivalent SNP’s
I attest that, in the event the above referenced organization has a CMS-approved institutional
equivalent SNP to provide services to community-dwelling enrollees who otherwise meet the
institutional status as determined by the state/territory, the I-SNP will assure that the necessary
arrangements with community resources are in place to ensure enrollees will be assessed and
receive services as specified by the I-SNP Model of Care.
I attest that if an I-SNP enrollee changes residence, the I-SNP will have appropriate
documentation that it is prepared to implement the I-SNP Model of Care at the enrollee’s new
residence, or disenroll the individual according to CMS enrollment/disenrollment policies and
procedures. Appropriate documentation includes any executed organization contract with the
LTC facility to provide the I-SNP Model of Care, and written documentation of the necessary
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arrangements in the community setting to ensure enrollees will be assessed and receive services
as required under the I-SNP Model of Care."
Authorized Representative Name (Print):________________________________
Authorized Representative Signature:____________________________________
Title:______________________________________________________________
Date:_______________________________________________________________
5.13.3. I-SNP Individuals Residing in Both Institutions and the Community
Please complete and upload this document into HPMS per the HPMS MA
Application User Guide instructions.
I-SNP Individuals Residing in Both Institutions and the Community
Upload Document
Applicants Contract Name (as provided in HPMS):_______________________
CMS Contract Number:_________________________________
1. For institutionalized individuals, provide a list of contracted long-term care
facilities. (Provide the names and addresses of the long-term care facilities)
2. For institutionalized individuals, provide the following attestation by the
authorized signatory.
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.
Authorized Representative Name (Print):________________________________
Authorized Representative Signature:____________________________________
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Title:______________________________________________________________
Date:_______________________________________________________________
3. For institutional equivalent individuals residing in the community, provide the
name, address, and relevant professional credential (e.g., RN for registered
nurse, LSW for licensed social worker, etc.) of the entity(ies) performing the
mandatory level of care (LOC) assessment for enrolling eligible individuals.
Name:____________________________________
Address:______________________________________________________________
Professional Credential:_________________________________________________
4. For institutional equivalent individuals residing in the community, provide a list
of applicable assisted living facilities or other residential facilities, e.g.,
continuing care communities. (Note: The use of Assisted Living Facilities or
other residential facilities is optional for I-SNPs that serve institutional
equivalent individuals in the community.)
a. Applicant is contracting with assisted-living facilities or other residential facilities at
the time of application. _____ Yes _____ No
b. If applicant is contracting with assisted-living facilities or other residential facilities,
enter the requested information below. (Provide the names and addresses of the
assisted living or other residential facilities)
5.14. ESRD Waiver Request Upload Document
Please complete and upload this document into HPMS per the HPMS MA
Application User Guide instructions.
Applicants Contract Name (as provided in
HPMS):_____________________________
Applicants CMS Contract
Number:__________________________________________
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 services
you provide are relevant to ESRD enrollees. Include a clinical and social profile of
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ESRD beneficiaries, their most frequent co-morbidities, problems with Activities of
Daily Living (ADLs), living arrangements, etc.
2. Provide a description 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)
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).
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. Name the organization(s)
b. 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
c. Describe the legal relationships between the applicant and the organization(s), and
d. Attach a copy of the fully executed contract between the health plan and the
organization(s)
5. Provide a list of the contracted nephrologist(s). Beneficiary access to
CONTRACTED (DO NOT LIST NON-CONTRACTED PROVIDERS)
nephrologists must meet the current HSD criteria. (Provide the names, medicare
provider numbers and addresses of the contracted Nephrologist(s))
6. Provide a list of the contracted dialysis facility(ies). Beneficiary access to
CONTRACTED (DO NOT LIST NON-CONTRACTED FACILITIES)dialysis
facilities must meet the current HSD criteria. (Provide the names, medicare
provider numbers and addresses of the contracted Dialysis Facility(ies))
7. List and describe (include relevant characteristics, details and/or qualities) the
dialysis options available to beneficiaries (e.g., home dialysis; nocturnal dialysis).
8. Provide a list of the CONTRACTED kidney transplant facility(ies). (Provide the
names, medicare provider numbers and addresses of the contracted kidney
transplant facility(ies))
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9. Describe beneficiary access to contracted kidney transplant facility(ies), including
the average distance beneficiaries in each county served by the applicants 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.
5.15. MOC Matrix Upload Document for Initial Application and Renewal
Please complete and upload this document into HPMS.
SNP Contract Name (as provided in HPMS)__________________________
SNP CMS Contract Number______________________
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.
All SNPs are required to develop and implement a Model of Care per regulations at: 42
CFR §422.101(f) and 42 CFR§422.152(g).
2. Description of the SNP Population:Element A: Description of the Overall SNP Population: The identification and
comprehensive description of the SNP-specific population is an integral component of the
MODEL OF CARE because all of the other elements depend on the firm foundation of a
comprehensive population description. The organization must provide information about its
local target population in the service areas covered under the contract. Information about
national population statistics is insufficient. It must provide an overview that fully addresses
the full continuum of care of current and potential SNP beneficiaries, including end-of-life
needs and considerations, if relevant to the target population served by the SNP. The
description of the SNP population must include, but not be limited to, the following:
Clear documentation of how the health plan staff determines or will determine, verify, and
track eligibility of SNP beneficiaries.
A detailed profile of the medical, social, cognitive, environmental, living conditions, and
co-morbidities associated with the SNP population in the plan’s geographic service area.
Identification and description of the health conditions impacting SNP beneficiaries,
including specific information about other characteristics that affect health such as,
population demographics (e.g. average age, gender, ethnicity, and potential health
disparities associated with specific groups such as: language barriers, deficits in health
literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations,
other).
Define unique characteristics for the SNP population served:
C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a C-SNP?
Include limitations and barriers that pose potential challenges for these C-SNP
beneficiaries.
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D-SNP: What are the unique health needs for beneficiaries enrolled in a D-SNP? Include
limitations and barriers that pose potential challenges for these D-SNP beneficiaries.
I-SNP: What are the unique health needs for beneficiaries enrolled in an I-SNP? Include
limitations and barriers that pose potential challenges for these I-SNP beneficiaries as
well as information about the facilities and/or home and community-based services in
which your beneficiaries reside.
Element B: Sub-Population: Most Vulnerable Beneficiaries
As a SNP, you must include a complete description of the specially-tailored services for
beneficiaries considered especially vulnerable using specific terms and details (e.g.,
members with multiple hospital admissions within three months, “medication spending
above $4,000”). The description must differentiate between the general SNP population and
that of the most vulnerable members, as well as detail additional benefits above and beyond
those available to general SNP members. Other information specific to the description of the
most vulnerable beneficiaries must include, but not be limited to, the following:
A description of the internal health plan procedures for identifying the most vulnerable
beneficiaries within the SNP.
A description of the relationship between the demographic characteristics of the most
vulnerable beneficiaries with their unique clinical requirements. Explain in detail how
the average age, gender, ethnicity, language barriers, deficits in health literacy, poor
socioeconomic status and other factor(s) affect the health outcomes of the most
vulnerable beneficiaries.
The identification and description of the established partnerships with community
organizations that assist in identifying resources for the most vulnerable beneficiaries,
including the process that is used to support continuity of community partnerships and
facilitate access to community services by the most vulnerable beneficiaries and/or their
caregiver(s).
2. Care Coordination:
Regulations at 42 CFR §422.101(f)(ii)-(v) and 42 CFR §422.152(g)(2)(vii)-(x) require all
SNPs to coordinate the delivery of care, and measure the effectiveness of the MODEL OF
CARE delivery of care coordination. Care coordination helps ensure that SNP beneficiaries’
healthcare needs, preferences for health services and information sharing across healthcare
staff and facilities are met over time. Care coordination maximizes the use of effective,
efficient, safe, and high-quality patient services that ultimately lead to improved healthcare
outcomes, including services furnished outside the SNP’s provider network as well as the care
coordination roles and responsibilities overseen by the beneficiaries’ caregiver(s). The
following MODEL OF CARE sub-elements are essential components to consider in the
development of a comprehensive care coordination program; no sub-element must be
interpreted as being of greater importance than any other. All five sub-elements below, taken
together, must comprehensively address the SNPs’ care coordination activities.
F. SNP Staff Structure
Fully define the SNP staff roles and responsibilities across all health plan functions that
directly or indirectly affect the care coordination of beneficiaries enrolled in the SNP.
This includes, but is not limited to, identification and detailed explanation of:
Specific employed and/or contracted staff responsible for performing administrative
functions, such as: enrollment and eligibility verification, claims verification and
processing, other.
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Employed and/or contracted staff that perform clinical functions, such as: direct
beneficiary care and education on self-management techniques, care coordination,
pharmacy consultation, behavioral health counseling, other.
Employed and/or contracted staff that performs administrative and clinical oversight
functions, such as: license and competency verification, data analyses to ensure
appropriate and timely healthcare services, utilization review, ensuring that providers
use appropriate clinical practice guidelines and integrate care transitions protocols.
Provide a copy of the SNP’s organizational chart that shows how staff responsibilities
identified in the MODEL OF CARE are coordinated with job titles. If applicable,
include a description of any instances when a change to staff title/position or level of
accountability was required to accommodate operational changes in the SNP.
Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical staff
functions.
Describe how the SNP conducts initial and annual MODEL OF CARE training for its
employed and contracted staff, which may include, but not be limited to, printed
instructional materials, face-to-face training, web-based instruction, and audio/videoconferencing.
Describe how the SNP documents and maintains training records as evidence to ensure
MODEL OF CARE training provided to its employed and contracted staff was
completed. For example, documentation may include, but is not limited to: copies of
dated attendee lists, results of MODEL OF CARE competency testing, web-based
attendance confirmation, and electronic training records.
Explain any challenges associated with the completion of MODEL OF CARE training
for SNP employed and contracted staff and describe what specific actions the SNP will
take when the required MODEL OF CARE training has not been completed or has been
found to be deficient in some way.
G. Health Risk Assessment Tool (HRAT)
Regulations at 42 CFR §422.101(f)(i); 42 CFR §422.152(g)(2)(iv) require that all SNPs
conduct a Health Risk Assessment for each individual enrolled in the SNP. The quality and
content of the HRAT should identify the medical, functional, cognitive, psychosocial and
mental health needs of each SNP beneficiary. The content of, and methods used to conduct
the HRAT have a direct effect on the development of the Individualized Care Plan and
ongoing coordination of Interdisciplinary Care Team activities; therefore, it is imperative that
the MODEL OF CARE include the following:
A clear and detailed description of the policies and procedures for completing the HRAT
including:
Description of how the HRAT is used to develop and update, in a timely manner, the
Individualized Care Plan (MODEL OF CARE Element 2C) for each beneficiary and
how the HRAT information is disseminated to and used by the Interdisciplinary Care
Team (MODEL OF CARE Element 2D).
Detailed explanation for how the initial HRAT and annual reassessment are conducted
for each beneficiary.
Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the
results of the HRAT, including the mechanisms to ensure communication of that
information to the Interdisciplinary Care Team, provider network, beneficiaries and/or
their caregiver(s), as well as other SNP personnel that may be involved with
overseeing the SNP beneficiary’s plan of care. If stratified results are used, include a
detailed description of how the SNP uses the stratified results to improve the care
coordination process.
H. Individualized Care Plan (ICP)
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Regulations at 42 CFR §422.101(f)(ii); 42 CFR §422.152(g)(2)(iv) require that all SNPs
must develop and implement an ICP for each individual enrolled in the SNP.
The ICP components must include, but are not limited to: beneficiary self-management
goals and objectives; the beneficiary’s personal healthcare preferences; description of
services specifically tailored to the beneficiary’s needs; roles of the beneficiaries’
caregiver(s); and identification of goals met or not met.
When the beneficiary’s goals are not met, provide a detailed description of the process
employed to reassess the current ICP and determine appropriate alternative actions.
Explain the process and which SNP personnel are responsible for the development of the
ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is involved in its
development and how often the ICP is reviewed and modified as the beneficiary’s
healthcare needs change. If a stratification model is used for determining SNP
beneficiaries’ health care needs, then each SNP must provide a detailed explanation of
how the stratification results are incorporated into each beneficiary’s ICP.
Describe how the ICP is documented and updated as well as, where the documentation is
maintained to ensure accessibility to the ICT, provider network, beneficiary and/or
caregiver(s).
Explain how updates and/or modifications to the ICP are communicated to the beneficiary
and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel and
other stakeholders as necessary.
I. Interdisciplinary Care Team (ICT)
Regulations at 42 CFR §422.101(f)(iii); 42 CFR §422.152(g)(2)(iv) require all SNPs to use
an ICT in the management of care for each individual enrolled in the SNP.
Provide a detailed and comprehensive description of the composition of the ICT; include
how the SNP determines ICT membership and a description of the roles and
responsibilities of each member. Specify how the expertise and capabilities of the ICT
members align with the identified clinical and social needs of the SNP beneficiaries, and
how the ICT members contribute to improving the health status of SNP beneficiaries. If a
stratification model is used for determining SNP beneficiaries’ health care needs, then
each SNP must provide a detailed explanation of how the stratification results are used to
determine the composition of the ICT.
Explain how the SNP facilitates the participation of beneficiaries and their caregivers as
members of the ICT.
Describe how the beneficiary’s HRAT (MODEL OF CARE Element 2B) and ICP
(MODEL OF CARE Element 2C) are used to determine the composition of the ICT;
including those cases where additional team members are needed to meet the unique
needs of the individual beneficiary.
Explain how the ICT uses healthcare outcomes to evaluate established processes to
manage changes and/or adjustments to the beneficiary’s health care needs on a
continuous basis.
Identify and explain the use of clinical managers, case managers or others who play
critical roles in ensuring an effective interdisciplinary care process is being conducted.
Provide a clear and comprehensive description of the SNP’s communication plan that
ensures exchanges of beneficiary information is occurring regularly within the ICT,
including not be limited to, the following:
Clear evidence of an established communication plan that is overseen by SNP personnel
who are knowledgeable and connected to multiple facets of the SNP MODEL OF
CARE. Explain how the SNP maintains effective and ongoing communication between
SNP personnel, the ICT, beneficiaries, caregiver(s), community organizations and other
stakeholders.
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The types of evidence used to verify that communications have taken place, e.g., written
ICT meeting minutes, documentation in the ICP, other.
How communication is conducted with beneficiaries who have hearing impairments,
language barriers and/or cognitive deficiencies.
J. Care Transitions Protocols
Regulations at 42 CFR §422.101(f)(2)(iii-v); 42 CFR §422.152(g)(2)(vii-x) require all SNPs
to coordinate the delivery of care.
Explain how care transitions protocols are used to maintain continuity of care for SNP
beneficiaries. Provide details and specify the process and rationale for connecting the
beneficiary to the appropriate provider(s).
Describe which personnel (e.g., case manager) are responsible for coordinating the care
transition process and ensuring that follow-up services and appointments are scheduled
and performed as defined in MODEL OF CARE Element 2A.
Explain how the SNP ensures elements of the beneficiary’s ICP are transferred between
healthcare settings when the beneficiary experiences an applicable transition in care. This
must include the steps that need to take place before, during and after a transition in care
has occurred.
Describe, in detail, the process for ensuring the SNP beneficiary and/or caregiver(s) have
access to and can adequately utilize the beneficiaries’ personal health information to
facilitate communication between the SNP beneficiary and/or their caregiver(s) with
healthcare providers in other healthcare settings and/or health specialists outside their
primary care network.
Describe how the beneficiary and/or caregiver(s) will be educated about indicators that
his/her condition has improved or worsened and how they will demonstrate their
understanding of those indicators and appropriate self-management activities.
Describe how the beneficiary and/or caregiver(s) are informed about who their point of
contact is throughout the transition process.
3.
SNP Provider Network
The SNP Provider Network is a network of healthcare providers who are contracted to provide
health care services to SNP beneficiaries. The SNP is responsible for a network description
that must include relevant facilities and practitioners necessary to address the unique or
specialized health care needs of the target population as identified in MODEL OF CARE 1,
and provide oversight information for all of its network types. Each SNP is responsible for
ensuring their MODEL OF CARE identifies, fully describes, and implements the following for
its SNP Provider Network:
D. Specialized Expertise
Regulations at 42 CFR§422.152(g)(2)(vi) require SNPs to demonstrate that the provider
network has specialized clinical expertise in delivery of care to beneficiaries.
Provide a complete and detailed description of the specialized expertise available to SNP
beneficiaries in the SNP provider network that corresponds to the SNP population
identified in MODEL OF CARE Element 1.
Explain how the SNP oversees its provider network facilities and ensures its providers are
actively licensed and competent (e.g., confirmation of applicable board certification) to
provide specialized healthcare services to SNP beneficiaries. Specialized expertise may
include, but is not limited to: internal medicine, endocrinologists, cardiologists,
oncologists, mental health specialists, other.
Describe how providers collaborate with the ICT (MODEL OF CARE Element 2D) and
the beneficiary, contribute to the ICP (MODEL OF CARE Element 2C) and ensure the
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delivery of necessary specialized services. For example, describe: how providers
communicate SNP beneficiaries’ care needs to the ICT and other stakeholders; how
specialized services are delivered to the SNP beneficiary in a timely and effective way;
and how reports regarding services rendered are shared with the ICT and how relevant
information is incorporated into the ICP.
E. Use of Clinical Practice Guidelines & Care Transitions Protocols
Regulations at 42 CFR §422.101 (f)(2)(iii)-(v);42 CFR§422.152(g)(2)(ix)require SNPs to
demonstrate the use of clinical practice guidelines and care transition protocols.
Explain the processes for ensuring that network providers utilize appropriate clinical
practice guidelines and nationally-recognized protocols. This may include, but is not
limited to: use of electronic databases, web technology, and manual medical record review
to ensure appropriate documentation.
Define any challenges encountered with overseeing patients with complex healthcare
needs where clinical practice guidelines and nationally-recognized protocols may need to
be modified to fit the unique needs of vulnerable SNP beneficiaries. Provide details
regarding how these decisions are made, incorporated into the ICP (MODEL OF CARE
Element 2C), communicated with the ICT (MODEL OF CARE Element 2D) and acted
upon.
Explain how SNP providers ensure care transitions protocols are being used to maintain
continuity of care for the SNP beneficiary as outlined in MODEL OF CARE Element 2E.
F. MODEL OF CARE Training for the Provider Network
Regulations at 42 CFR§422.101(f)(2)(ii) require that SNPs conduct MODEL OF CARE
training for their network of providers.
Explain, in detail, how the SNP conducts initial and annual MODEL OF CARE training
for network providers and out-of-network providers seen by beneficiaries on a routine
basis. This could include, but not be limited to: printed instructional materials, face-to-face
training, web-based instruction, audio/video-conferencing, and availability of instructional
materials via the SNP plans’ website.
Describe how the SNP documents and maintains training records as evidence of MODEL
OF CARE training for their network providers. Documentation may include, but is not
limited to: copies of dated attendee lists, results of MODEL OF CARE competency
testing, web-based attendance confirmation, electronic training records, and physician
attestation of MODEL OF CARE training.
Explain any challenges associated with the completion of MODEL OF CARE training for
network providers and describe what specific actions the SNP Plan will take when the
required MODEL OF CARE training has not been completed or is found to be deficient in
some way.
4. MODEL OF CARE Quality Measurement & Performance Improvement:
Regulations at 42 CFR §422.152(g) require that all SNPs conduct a quality improvement
program that measures the effectiveness of its MODEL OF CARE. The goals of performance
improvement and quality measurement are to improve the SNP’s ability to deliver healthcare
services and benefits to its SNP beneficiaries in a high-quality manner. Achievement of those
goals may result from increased organizational effectiveness and efficiency by incorporating
quality measurement and performance improvement concepts used to drive organizational
change. The leadership, managers and governing body of a SNP organization must have a
comprehensive quality improvement program in place to measure its current level of
performance and determine if organizational systems and processes must be modified based
on performance results.
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C. MODEL OF CARE Quality Performance Improvement Plan
Explain, in detail, the quality performance improvement plan and how it ensures that
appropriate services are being delivered to SNP beneficiaries. The quality performance
improvement plan must be designed to detect whether the overall MODEL OF CARE
structure effectively accommodates beneficiaries’ unique healthcare needs. The
description must include, but is not limited to, the following:
The complete process, by which the SNP continuously collects, analyzes, evaluates and
reports on quality performance based on the MODEL OF CARE by using specified
data sources, performance and outcome measures. The MODEL OF CARE must also
describe the frequency of these activities.
Details regarding how the SNP leadership, management groups and other SNP
personnel and stakeholders are involved with the internal quality performance process.
Details regarding how the SNP-specific measurable goals and health outcomes
objectives are integrated in the overall performance improvement plan (MODEL OF
CARE Element 4B).
Process it uses or intends to use to determine if goals/outcomes are met, there must be
specific benchmarks and timeframes, and must specify the re-measurement plan for
goals not achieved.
D. Measureable Goals & Health Outcomes for the MODEL OF CARE
Identify and clearly define the SNP’s measureable goals and health outcomes and
describe how identified measureable goals and health outcomes are communicated
throughout the SNP organization. Responses must include but not be limited to, the
following:
Specific goals for improving access and affordability of the healthcare needs outlined
for the SNP population described in MODEL OF CARE Element 1.
Improvements made in coordination of care and appropriate delivery of services
through the direct alignment of the HRAT, ICP, and ICT.
Enhancing care transitions across all healthcare settings and providers for SNP
beneficiaries.
Ensuring appropriate utilization of services for preventive health and chronic
conditions.
Identify the specific beneficiary health outcomes measures that will be used to measure
overall SNP population health outcomes, including the specific data source(s) that will be
used.
Describe, in detail, how the SNP establishes methods to assess and track the MODEL OF
CARE’s impact on the SNP beneficiaries’ health outcomes.
Describe, in detail, the processes and procedures the SNP will use to determine if the
health outcomes goals are met or not met.
Explain the specific steps the SNP will take if goals are not met in the expected time
frame.
C. Measuring Patient Experience of Care (SNP Member Satisfaction)
Describe the specific SNP survey(s) used and the rationale for selection of that particular
tool(s) to measure SNP beneficiary satisfaction.
Explain how the results of SNP member satisfaction surveys are integrated into the
overall MODEL OF CARE performance improvement plan, including specific steps to be
taken by the SNP to address issues identified in response to survey results.
D. Ongoing Performance Improvement Evaluation of the MODEL OF CARE
Explain, in detail, how the SNP will use the results of the quality performance indicators
and measures to support ongoing improvement of the MODEL OF CARE, including how
quality will be continuously assessed and evaluated.
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Describe the SNP’s ability to improve, on a timely basis, mechanisms for interpreting and
responding to lessons learned through the MODEL OF CARE performance evaluation
process.
Describe how the performance improvement evaluation of the MODEL OF CARE will
be documented and shared with key stakeholders.
E. Dissemination of SNP Quality Performance related to the MODEL OF CARE
Explain, in detail, how the SNP communicates its quality improvement performance
results and other pertinent information to its multiple stakeholders, which may include,
but not be limited to: SNP leadership, SNP management groups, SNP boards of directors,
SNP personnel & staff, SNP provider networks, SNP beneficiaries and caregivers, the
general public, and regulatory agencies on a routine basis.
This description must include, but is not limited to, the scheduled frequency of
communications and the methods for ad hoc communication with the various
stakeholders, such as: a webpage for announcements; printed newsletters; bulletins; and
other announcement mechanisms.
Identify the individual(s) responsible for communicating performance updates in a timely
manner as described in MODEL OF CARE Element 2A.
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APPENDIX II: Employer/Union-Only Group Waiver
Plans (EGWPs) MAO “800 Series”
6.
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 and MAOs 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 MAPD 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.
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 2021 Solicitation for Applications for New Medicare
Advantage Prescription Drug Plan (MA-PD) Sponsors. The 2021 Solicitation
for Applications for New Medicare Advantage Prescription Drug Plan (MAPD) Sponsors must also be submitted electronically through HPMS. These
requirements are also applicable to new MAOs applying to offer “800 series”
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Regular MSA or Demonstration MSA plans that do not intend to offer plans
to individual beneficiaries in 2021. Together these documents will comprise a
completed application for new MAOs. Failure to complete, if applicable, the
2021 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.
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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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,
understand, and agree to comply with the above statement about service areas. If I need
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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 2021 MA Applications and the 2021 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 2021 MA Application and the 2021 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 2021 Part D
bid (i.e., bid pricing tool) in order to offer its EGWPs. (Section 2.7 of the 2021
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
meet the needs of its enrollees throughout the employer/union-only group waiver
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service area, including situations involving emergency access, as determined by
CMS. Applicant acknowledges and understands that CMS reviews the adequacy
of the applicants’ 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 applicants network is sufficient to meet the needs of its
employer group population. (See the 2021 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 2021
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”). Applicants EGWPs. (Sections 3.6.A10 and
3.24.A2-A4 of the 2021 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 2021 Solicitation for New
Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)
10) Applicant understands that its EGWPs are 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 employers and unions, the timing for issuance of the
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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 2021
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 2021 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 2021
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 2021
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
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.
Instructions
All Direct Contract MA applicants must complete and submit the following:
(1) The 2021 MA Application. This portion of the appendix is submitted electronically
through the HPMS.
(2) The 2021 Part C Financial Solvency & Capital Adequacy Documentation Direct
Contract MA Application. This portion of the appendix is submitted electronically
through HPMS.
(3) The 2021 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 2021 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).
Note: 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 2021
Solicitation for Applications for New Medicare Advantage Prescription Drug Plan
(MA-PD) Sponsors and the 2021 Solicitation for Applications for New
Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MAPD) Sponsors.
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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Attestations
Direct Contract MA Attestations
1.SERVICE AREA REQUIREMENTS
In general, MAOs can cover beneficiaries only in the service areas in which they are state
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 2021 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 2021 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 2021 MA
Application in addition to this 2021 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 2021 Solicitation for Applications for New Medicare Advantage
Prescription Drug Plan (MA-PD) Sponsors and the 2021 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 2021
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 2021 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 2021 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 2021 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 2021 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 2021 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
2021 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 2021 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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Part C Financial Solvency & Capital Adequacy Documentation For Direct Contract
MAO applicants
1.
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.
IDENTIFY 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
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
applicants 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
applicants 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 applicants 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 un2021 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 applicants 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 applicants 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 applicants 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 MAOs.
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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Page 129 of 129
| File Type | application/pdf |
| File Title | PART 1 GENERAL INFORMATION |
| Author | Emmanuelle Goodrich |
| File Modified | 2019-12-16 |
| File Created | 2019-12-16 |