Medicare Advantage Applications - Part C

12-5-2009

High-Level Summary of All Part C Application Revisions from 2009 Version of Part C Application to 2010 Version

Clarification		Purpose of the Clarification		Application
				Part C Application		800 series (PDP and Cost)		SNP
GENERAL INFORMATION and INSTRUCTIONS
Updated dates (language where appropriate) and regulatory and Medicare Managed Care Manual references for each attestation section.		Updated dates (language where appropriate) and references to statutes, regulations and Part C guidance.		Throughout document		Throughout document
Clarified instructions related to the application submission and correction process.		Clarified instructions related to the courtesy opportunity to cure deficiencies, the Notice of Intent to Deny process to cure deficiencies, and the retail pharmacy access review process.		Instructions		N/A		N/A
Clarified instructions related to the application submission for the EGHP for Local CCP applications		Clarified instructions to the courtesy opportunity to update application and insert new Employer Group Waiver Information that was published, late last year, by CMS for Employer Group Waivers Plans		N/A		Clarified existing EGWP policies for “800 series” Local Coordinated Care Plans		N/A
Clarification of current Name of Center and Group.		CMS had a recent reorganization that changed the names of the Center and Group we have updated Names.		Instructions		Instructions		Instructions
Payment Information. Changed regulation citation to reflect current regulation.		Revisions to the Medicare Advantage Program and Part D Prescription Drug Contract Appeals and Intermediate Sanction Process, Final rule 12/5/07. This information provides information regarding the regulatory standard of substantial compliance, the burden of proof and applicable timeframes for appeals that are an important part of the application process.		Instructions		Instructions		Instructions
Inserted clarifying instructions on how to withdraw a pending application.		To provide written instructions to support applicants in understand the process and expediting its request to withdraw a application.		10.5 General Instructions.
Deleted Appeals Language		Information was outdated.		10.6 General Instructions
ALL MA APPLICANTS, CONTRACTS, LICENSURE AND FINANCIAL STABILITY
Added licensure information to alert applicants of that they need to provide proof of insurance and auto-renewal for the contract year period.		Clarified language related to a requirement for the application Language was clarified to reflect CMS authority related to the application request-requiring applicant have sufficient insurance to prove solvency.		1.2 #13		N/A		N/A
Added language to address the scope of the requirement for a State license		This is in accordance with Section 42 CFR 422.400(c) “demonstrate to CMS that - scope of its license or authority allows the organization to offer the type of MA plan or plans that it intends to offer in the State and if applicable, has obtained in the State recertification requirement under paragraph (b) of this section”		1.3 #1		N/A		N/A
Clarified contractual requirements related to the MMA and Compliance regulation.		Added the parties to whom the disciplinary standards apply.		1.5 #6		N/A		N/A
Clarified contractual requirement related to MMA.		Clarification is a result of industry request since the previous descriptions were not clear. Current description of maps was taken verbatim from the Feb. 20, 2008 FAQ to industry.		1.8 C.		N/A		N/A
Clarified contractual requirements related to the MMA and the Compliance regulation.		The contractual provisions were clarified to properly reflect CMS authority under the compliance regulation related to CMS or its designee’s access to books and records related to the Part C program.		1.9 #2, entire section.		N/A		N/A
Clarified the types of marketing materials that must on the applicants’ web site, if application is approved.		Updated language referencing marketing guidelines. Based on section 103 of MIPPA, which establishes new statutory prohibitions and limitations for MA Plans and certain sales and marketing activities.		3.3 C3		N/A		N/A
Clarified the state licensure regulations for RPPO’s		Updated language in accordance with 42 CFR 422.400(c) “demonstrate to CMS that the scope of the license or authority allows the organization to offer the type of MA plans that it intends to offer in the State and if applicable, has obtained the State certification required under paragraph (b) of this section.”		2.1 (A) (1)		N/A		N/A
We deleted the existing Section 2. Service Area Expansion for RPPO Applicants Only.		We deleted this section because it was misleading. RPPO’s may not have service area expansions. In order to expand an RPPO must apply as a new RPPO applicant.		Section 2		N/A		N/A
We deleted the existing Part 4 since MIPPA changed the rules for Special Needs Plans.						N/A		N/A
We have completely revised Part 4 of this application in order to incorporate and implement the MIPPA changes to the SNP requirements.	Section 164 of MIPPA- Revisions Relating to Specialized Medicare Advantage Plans for Special Needs Individuals Extensively changed the rules for SNP plans. This section places a moratorium on designated new disproportionate share SNPs for 2010. The following summarized the changes in the section. _ Enrollment - requires 100% new enrollment dual eligible, requires state benefit coordination, Chronic SNPs also require 100% of new enrollees on or after 2101 have chronic conditions Have quality reporting requirements. Section 165 Limitation on Our-Of-Pocket Costs for Dual Eligible and Qualified Medicare Beneficiaries Enrolled in a Specialized Medicare Advantage Plan for SNP Individuals Section 167 Access to Medicare Reasonable Cost Contract Plans Extends contract cost reporting Amends the test for determining whether a cost contract must terminate after 2110.		Revised section 4 All of document		NA		N/A
Updated PFFS Attestation language	To provide accurate policy information regarding PFFS requirements.		Section 3: PFFS plans.
UPLOADS
Clarified contractual requirements related to the MMA and industry comments	The contractual provisions clarified to reflect CMS authority under the regulations related to CMS requesting state certification information. Added CFO signature on attestation in order to verify the type of MA application for which the MAO is applying. Add section in response to some states’ concerns about attesting to the type of plan for which the MAO was applying. The changes reflect that the state is not certifying to the type of application, rather the scope of the license. Deleted “that the aforementioned organization is authorized to bear the risk associated with the type of Medicare Advantage contracts indicated above.		Throughout document		NA			NA
Clarification of requirements for CMS provider participation contracts and/or agreement matrix -1.	Updated language and references to statues, regulations and Part C guidance.		Throughout document					N/A
Redesigned HSD table 1 and updated the instructions to match the redesign.	To expedite the CMS review of HSD table 1 by allow CMS internal system to calculate the data in HSD table 1.		2.7.1

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