PART C -MEDICARE ADVANTAGE
APPLICATION
For all new applicants and existing Medicare Advantage contractors seeking to expand a service area -- CCP, PFFS, MSA, RPPO, and SNPs.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services (CMS)
Center for Drug and Health Plan Beneficiary Choice (CPC)
Medicare Drug and Health Plan Contract Administration Group (MCAG)
Medicare Advantage Coordinated Care Plans (CCPs) must offer Part D prescription drug benefits under at least one Medicare Advantage plan in each county of its service area, and therefore must timely submit a Medicare Advantage-Prescription Drug(MA-PD) application to offer Part D prescription drug benefits as a condition of approval this application.
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. The time required to complete this information collection is estimated to average 32 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.
PART 1 GENERAL INFORMATION 3
1. Overview 3
2. Types of MA Products and MA Applicants 3
3. Important References 4
4. Technical Support 4
5. Health Plan Management System (HPMS) 5
6. Submit Intent to Apply 5
7. Due date For MA Application 6
8. General MA Application Instructions 6
9. MA Part D (MA-PD) Prescription Drug Benefit Instructions 7
10. Additional Information 7
PART 2 INITIAL APPLICATIONS 11
SECTION 1 ALL MA APPLICANTS (CCP, PFFS, RPPO, & MSA) 12
SECTION 2 REGIONAL PREFERRED PROVIDER ORGANIZATION (RPPO) APPLICANTS ONLY 40
SECTION 3 PRIVATE FEE FOR SERVICE (PFFS) APPLICANTS ONLY 44
SECTION 4 MEDICAL SAVINGS ACCOUNTS (MSA) & MSA DEMO APPLICANTS ONLY 48
SECTION 5 MSA DEMONSTRATION APPLICANTS ONLY 49
PART 3 SERVICE AREA EXPANSION APPLICATIONS 51
SECTION 1 ALL MA APPLICANTS except RPPO’s 51
SECTION 2 SERVICE AREA EXPANSIONS FOR RPPO APPLICANTS ONLY 59
PART 4 SOLICITATIONS FOR SPECIAL NEEDS PLAN PROPOSAL 63
PART 5 INSTRUCTIONS FOR COMPLETING CMS FORMS 93
PART 6 LISTS OF REQUESTED DOCUMENTS 113
In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (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 MA organizations). The MMA changes make managed care more accessible, efficient, and attractive to beneficiaries seeking options to meet their needs. The MA program offers new kinds of plans and health care choices, such as regional preferred provider organization plans (RPPOs), private fee-for-service plans (PFFS), Special Needs Plans (SNPs), and Medical Savings Account plans (MSAs).
The Medicare outpatient prescription drug benefit is a landmark addition to the Medicare program. More people have prescription drug coverage and are saving money on prescription drugs than ever before. Costs to the government for the program are lower than expected, as are premiums for prescription drug plans.
People with Medicare not only have more quality health care choices than in the past but also more information about those choices. The Centers for Medicare & Medicaid Services (CMS) welcome organizations that can add value to these programs make them more accessible to Medicare beneficiaries and meet all the contracting requirements.
The MA program is comprised of a variety of product types including:
Coordinated Care Plans
Health Maintenance Organizations (HMOs) with/without a Point of Service(POS) benefit
Local Preferred Provider Organizations (LPPOs)
Regional Preferred Provider Organizations (RPPOs)
State Licensed Provider-Sponsored Organizations (PSOs)
Special Needs Plans
Private Fee-for-Service (PFFS) plans
Medical Savings Account plans (including Medical Savings Account Demonstration plans)
Note: For facts sheets on each of these types of product offerings go to http://www.cms.hhs.gov/HealthPlansGenInfo/
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.
Either the applicant can be “new”, meaning the applicant is seeking a new MA contract for a type of MA product they do not already offer, or “existing”, meaning the applicant is seeking a service area expansion under an existing contract.
Note: The Medicare Modernization Act requires that CCPs offer at least one MA plan that includes a Part D prescription drug benefit (an MA-PD) in each county of its service area. To meet this requirement, the applicant must timely complete and submit a separate Medicare Advantage Group Prescription Drug Plan application (MA-PD application) in connection with the MA-PD.
Note: PFFS plans have the option to offer the Part D drug benefit. MSA plans cannot offer the Part D drug benefit.
Note: All applicants who wish to offer Employer/Union-Only Group Waiver Plan must complete a separate EGWP application in HPMS. There are two types of EGWP applications: MAO “800 Series” EGWP application and Employer/Union Direct Contract PFFS MAO application.
The following are key references about the MA program:
Social Security Act -- 42 USC 1395 et seq. http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
Medicare Regulations--42 CFR Part 422
Medicare Managed Care Manual--http://www.cms.hhs.gov/HealthPlansGenInfo/
Medicare Marketing Guidelines –http://www.cms.hhs.gov/ManagedCareMarketing/
CMS Central and Regional Office staffs are available to provide technical support to all applicants during the application process. Applicants may call Letticia Ramsey in the CMS Central Office at (410) 786-5262, or by email Letticia.Ramsey @cms.hhs.gov or a Regional Office to request assistance. A list of CMS Regional Office contacts in Part 7 of this application.
For general information about this application, please send an email to the following email address: PartCappComments@cms.hhs.gov
CMS also conducts special training sessions and user group calls for new applicants and existing contractors. All applicants are strongly encouraged to participate in these sessions that will be announced via HPMS and/or CMS main website.
A. The HPMS is the primary information collection vehicle through which MA organizations will communicate with CMS in support of the application process, bid submission process, ongoing operations of the MA program, and reporting and oversight activities.
B. Applicants are required to enter contact and other information collected in HPMS in order to facilitate the application review process. Applicants are required to provide prompt entry and ongoing updates of data in HPMS. By keeping the information in HPMS current, the applicant facilitates the tracking of its application throughout the review process and ensures that CMS has the most current information for application updates, guidance and other types of correspondence. In the event that an applicant is awarded a contract, this information will also be used for frequent communications during implementation. Therefore, it is important that this information be accurate at all times.
C. HPMS is also the vehicle used to disseminate CMS guidance to MA organizations. The information is then incorporated in the appropriate manuals. It is imperative for MA organizations to independently check HPMS notices and incorporate the guidance as indicated in the notices.
Organizations interested in offering a new Medicare Advantage product or expanding the service area of an existing product must complete a Notice of Intent to Apply by November 18, 2008. 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 the new 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: http://www.cms.hhs.gov/AccesstoDataApplication/Downloads/Access.pdf . Upon approval of the CMS User ID request, the applicant will receive a CMS User ID(s) and password(s) for HPMS access. Existing MAO’s requesting service area expansions do not need to apply for a new MAO number.
Applications must be submitted by 11:59 P.M.EST, February 26, 2010. CMS will not review applications received after this date and time. Applicants’ 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) application review process:
APPLICATION REVIEW PROCESS * |
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Date |
Milestone |
November 18, 2008
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New MA organizations: 1. Submit notice of intent to apply to CMS 2. Request HPMS Access (Includes User ID and Password Request) 3. Request CMS Connectivity |
January 6, 2009 |
Final Applications Posted by CMS |
February 26, 2009 |
Applications due
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April 1, 2009 |
First round deficiency emails |
April 5, 2009 |
First round correction due |
April 24, 2009 |
Notices of Intent to deny |
May 4, 2009 |
Reponses to Notice of Intent to Deny due |
June 2009 |
All bids due. |
September 2009 |
CMS completes review and approval of bid data. CMS executes Part C (MA program) contract to organizations that submit an acceptable bid, and otherwise meet CMS requirements. |
November 2009 |
2009 Annual Coordinated Election Period begins for January 1, 2010 effective date for 2010 plans. |
* Note: all dates listed above are subject to change.
Applicants must complete the 2010 MA application using the HPMS as instructed. CMS will not accept any submission using prior versions of the MA application. All documentation must contain the appropriate CMS issued contract number.
In preparing a response to the prompts throughout this application, the Applicant must mark “Yes” or “No” in sections organized with that format. By responding “Yes”, the Applicant is committing its organization to being operationally compliant with the relevant requirement as of the date the Medicare contract is signed.
CMS may verify an Applicant’s readiness and compliance with Medicare requirements, through on-site visits at the Applicant’s facilities as well as through other program monitoring techniques. Failure to meet the requirements represented in this application and to operate MA plans consistent with the applicable statutes, regulations, and the MA contract, and other CMS guidance could result in the suspension of plan marketing and enrollment. If corrections are not made in timely manner, the Applicant will be disqualified from participation in the MA program.
Throughout this application, applicants are asked to provide various documents and/or tables in HPMS. Part 5 of this application lays out instructions for completing some of the requested CMS forms and tables. Part 6 of this application provides a list of all requested documents and/or tables. The list includes the name, the reference point within the application, the format to use when submitting the application, and a file naming nomenclature.
The legal entity that submits this application must be the same entity with which CMS enters into a MA contract.
The MA-PD application 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 MA-PD application 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 MA-PD application can be found at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage or the applicant may contact Marla Rothouse at 410-786-8063 or Linda Anders at 410-786-0459. Specific instructions to guide MA applicants in applying to qualify to offer a Part D benefit during 2010 are provided in the MA-PD application and must be followed.
Note: Failure to file the required MA-PD application will be considered an “incomplete” MA application and could result in a denial of this application.
Failure to submit application supporting documentation consistent with these instructions may delay the review by CMS and may result in the applicant receiving a Notice of Intent to Deny.
10.1 Bid Submission and Training
On or before the first Monday of June of every year, MA organizations must submit a bid, comprised of the proper benefits and pricing for each MA plan for the upcoming year based on its 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. MA Organizations must submit the benefit plan or plans it intends to offer under the bids submitted. No bid submission is needed at the time the application is submitted. Further instructions and time frames for bid submissions are provided at http://www.cms.hhs.gov/MedicareAdvantageApps.
In order to prepare plan bids, Applicants will use HPMS to define its plan structures, 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 its MA benefit and the BPT software to define its bid pricing information.
Once the PBP and BPT software have been completed for each plan being offered, Applicants will upload their bids to HPMS. Applicants will be able to submit bid uploads to HPMS on its PBP or BPT one or more times between early May 2009 and the CY 2010 bid deadline, the first Monday in June 2009. CMS will use the last successful upload received for a plan as the official bid submission.
CMS will provide technical instructions and guidance upon release of the HPMS bid functionality as well as the PBP and BPT software. In addition, systems training will be available at the Bid Training in April 2009.
10.2 System and Data Transmission Testing
All MA organizations must submit information about its membership to CMS electronically and have the capability to download files or receive electronic information directly. Prior to the approval of a contract, MA organizations must contact the MMA Help Desk at 1-800-927-8069 for specific guidance on establishing connectivity and the electronic submission of files. Instructions are also on the MMA Help Desk web page, www.cms.hhs.gov/mmahelp, in the Plan Reference Guide for CMS Part C/D systems link. The MMA Help Desk is the primary contact for all issues related to the physical submission of transaction files to CMS.
10.3 Protecting Confidential Information
Applicants may seek to protect its 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 Exemption 4, CMS is required by its FOIA regulation at 45 CFR §5.65(d) and by Executive Order 12,600 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; or (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. Consistent with our approach under other Medicare programs, CMS would not release information that would be considered proprietary in nature.
10.4 Payment Information Form
Please complete the Payment Information form that is located at:
http://www.cms.hhs.gov/MedicareAdvantageApps/Downloads/pmtform.pdf
The document contains financial institution information and Medicare contractor data.
If the applicant has questions about this form please contact Yvonne Rice at 410-786-7626. The completed form needs to be faxed to Yvonne Rice at (410) 786-0322.
10.5 Withdrawing a Pending Initial And Service Area Application Requests:
Prior to the June 1, 2009 MA and MA/PD bid submission date, applicant organizations seeking to withdraw an entire pending application or seeking to withdraw counties and/or zip codes from a pending application must contact CMS by email or send us this type of request. Emails should be sent to MA_Applications@cms.hhs.gov. Mail requests should be addressed to:
MCAG/DMAO/CAT
Attn: Contracting and Application Team
Mail Stop: C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
The official request to withdraw the application, counties and/or zip codes must be submitted to CMS on the organization’s letterhead and signed by an authorized corporate official. If an organization’s request is emailed, the request itself must be in the form of an attachment in a PDF file. The following information must be included in the letter:
Applicant Organization’s Legal Entity Name
Full and Correct Address and Point of Contact information for follow-up, if necessary
Contract Number (H#)
Exact Description of the Nature of the Withdrawal:
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)
Withdrawal of the entire application.
Withdrawal of specifically named counties from both individual Medicare and employer group markets
10.6 Application Determination Appeal Rights
If CMS determines that the applicant is not qualified to enter into a contract with CMS under Part C of Title XVIII of the Social Security Act 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-PD application denials are governed by 42 CFR Part 422, Subpart N. The request for a hearing must be in writing, signed by an authorized official of applicant organization and received by CMS within 15 calendar days from the date CMS notifies the MAO organization of its determination (See 42 CFR 422.662.) If the 15th day falls on a weekend or federal holiday, you have until the next regular business day to submit your request.
The appealing organization must receive a favorable determination resulting from the hearing or review as specified under Part 422, Subpart N prior to July 15, 2009 in order to qualify for a Medicare contract to begin January 1, 2010.
The MA application must be completed using the HPMS except as indicated otherwise throughout this document. Section 1 of the application, must be completed by all applicants applying for a new contract type (e.g. CCP, PFFS, MSA, or RPPO or SNP) for which the applicant does not already have a Medicare contract. If the applicant is seeking a service area expansion or a new SNP type under an existing Medicare contract, then an initial application should not be completed; rather a Service Area Expansion Application must be completed. Applicants applying for a Regional PPO, PFFS, or MSA, or Special Needs plan must also complete the section specific to that product.
CMS strongly recommends and encourages Medicare Advantage applicants to refer to the 42 CFR Part 422 regulations to clearly understand the nature of the requirement in order to provide an appropriate response. Nothing in this application is intended to supersede the regulations at 42 CFR Part 422. 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 of 42 CFR. Applicants must read HPMS notices and visit the CMS web site periodically to stay informed about new or revised guidance documents.
SECTION 1 ALL MA APPLICANTS (CCP, PFFS, RPPO, & MSA)
1.1 Experience & Organization History
In HPMS, upload a brief summary of the applicant’s history, structure and ownership. Include organizational charts to show the structure of ownership, subsidiaries, and business affiliations.
1.2 Administrative Management
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ADMINISTRATIVE MANAGEMENT |
YES |
NO |
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1.3 State Licensure (For CCP, PFFS, & MSA Applicants Only)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE |
YES |
NO |
● If “Yes,” applicant must provide in HPMS an executed copy of a state licensing certificate and/or the CMS state certification form for each state being requested.
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Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 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.
Note: For states or territories such as Puerto Rico whose licenses renew after June 1, the applicant is required to submit the new license in order to operate as an MA or MA-PD.
1.4 Business Integrity
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: BUSINESS INTEGRITY |
YES |
NO |
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B. If Applicant answered “No” to either question above; upload in HPMS a Business Integrity Disclosure, which contains a brief explanation of each action, including the following:
1.
Legal names of the parties.
2. Circumstances.
3. Status
(pending or closed)
4. If closed, provide the details concerning resolution and any monetary payments, or settlement agreements or corporate integrity agreement.
1.5 Compliance Plan
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMPLIANCE PLAN |
YES |
NO |
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Note: This requirement cannot be delegated to a subcontractor (first tier, downstream, and related entities).The applicant’s compliance officer must be an employee of the applicant. This position cannot be delegated to a subcontractor (first tier, downstream, or related entities).
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Note: All compliance plans must be implemented no later than the effective date of the pending contract. For example: January 1, 2010.
1.6 Key Management Staff
A. In the HPMS Contract Management/Contract Information/Contract Data page, provide the name/title; mailing address; phone number; fax number; and email address for the following Applicant contacts:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENT: KEY MANAGEMENT STAFF |
YES |
NO |
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Applicant agrees that all staff is qualified to perform duties as assigned.
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Contact |
Name/Title |
Mailing Address |
Phone/Fax Numbers |
Email Address |
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Corporate Mailing |
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CEO – Sr. Official for Contracting |
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Chief Financial Officer |
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Medicare Compliance Officer |
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Enrollment Contact |
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Medicare Coordinator |
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System Contact |
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Customer Service Operations Contact |
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General Contact |
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User Access Contact |
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Backup User Access Contact |
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Marketing Contact |
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Medical Director |
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Bid Primary Contact |
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Payment Contact |
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HIPAA Security Officer |
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HIPAA Privacy Officer |
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CEO- CMS Administrator Contact |
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Quality Director |
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B. Provide in HPMS, position descriptions for the key management staff and an organizational chart showing the relationships of the various departments.
1.7 Fiscal Soundness
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: FISCAL SOUNDNESS |
YES |
NO |
(Note: All applicants with three months or less of operations must provide CMS with a financial plan discussed in section 2. below). |
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1.8 Service Area
In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area the applicant wish to serve.
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: SERVICE AREA |
YES |
NO |
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Provide in HPMS, detailed maps of the requested service area showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. Maps should indicate contracted ambulatory and hospital providers, and mean travel times.
For each county in the requested service area, there should be four separate maps. The first map should reflect the boundaries of the county as well as main traffic arteries (highways, interstates) and any physical barriers such as mountains or rivers. This map should include contracted ambulatory (outpatient-stand alone) facilities with the mean travel times to each location. The second map should indicate all contracted hospitals, skilled nursing facilities, rehabilitation facilities and psychiatric hospitals. Each specialty type should be delineated as a separate color or symbol. The third map should contain all contracted primary care providers. The fourth map should contain all contracted specialty providers. Each speciality type should be delineated as a separate color or symbol.
note: RPPO applicants’ geographic maps should be defined by rural and urban areas (include borders) that demonstrate the locations of all contracted providers in relation to the beneficiaries in those areas.
Note: The service area for the MSA demonstration plan can only be offered at the entire state or territory level.
1.9 Provider Contracts & Agreements
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PROVIDER CONTRACTS & AGREEMENTS |
YES |
NO |
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Provide in HPMS a completed “CMS Provider Arrangements by County Table”. Applicant should insert the number of provider contracts and/or agreements for each proposed service area or distinctive system(s) applicant.
Provide in HPMS a sample copy of each primary provider contract(s) and agreement(s) between the applicant and its health care contractors (i.e., direct contract with physicians, medical group, IPA, PHO, hospitals, skilled nursing facilities, etc.).
Provide in HPMS, a sample copy of each downstream subcontract that may exist between a Medical groups, IPAs, PHO, etc. and other providers (i.e., individual physicians). (For example: If the applicant contracts with an IPA, which contracts with individual physicians, the applicant must provide in HPMS a sample copy of the contract/agreement between the IPA and physicians).
Provide in HPMS, a completed “CMS Provider Participation Contracts and/or Agreements Matrix”, which is a crosswalk of CMS regulations to provider contracts and/or agreements. Applicant should complete a matrix for each applicable primary contracted provider and subcontracted provider.
Note: As part of the application process, applicants will be instructed to provide a sample of provider contract signatures. Applicants will receive further instructions by their CMS reviewer.
1.10 Contracts for Administrative & Management Services
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE & MANAGEMENT SERVICES |
YES |
NO |
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Note: PFFS or MSA plans are not required to perform utilization operations. |
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B. In HPMS, complete the table below.
DELEGATED BUSINESS FUNCTION |
SUBCONTRACTOR(S) |
Beneficiary Call Center(example) |
ABC Limited |
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C. Applicant must provide in HPMS, executed delegated administrative services/management contracts or letters of agreement for each contractor or subcontractor (first tier, downstream, and related entities) identified in the chart (Section 1.10 B) above that:
Clearly identify the parties to the contract (or letter of agreement).
Describes each of the specific functions (health and/or administrative) that are now or will be delegated to medical groups, IPAs, or other intermediate entities.
Describes how the applicant will remain accountable for any functions or responsibilities that are delegated to other entities.
Describes how the applicant will oversee, and formally evaluate delegated entities.
Describes the applicant's relationships to related entities, contractors and sub-contractors with regard to provision of health and/or administrative services specific to the Medicare product.
Contains language clearly indicating that the delegated entity, contractor, or subcontractor (first tier, downstream, and related entities) has agreed to perform the health and/or administrative service, and clauses requiring their activities be consistent and comply with the Applicant’s contractual obligations.
Are signed by a representative of each party with legal authority to bind the entity.
Contains language obligating the contractor or subcontractor (first tier, downstream, and related entities) to abide by all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 422 (504)(i)(4)(v).
Contains language obligating the subcontractor (first tier, downstream, and related entities)to abide by State and Federal privacy and security requirements, including the confidentiality and security provisions stated in the regulations for this program at 42 CFR §422.504(a)(13).
Contains language ensuring that the contractor or subcontractor (first tier, downstream, and related entities) will make its books and other records including medical records and documentation involving transactions related to CMS’ contract with the MA organization available in accordance with 42 CFR 422.504 (i) (2). Generally stated these regulations give HHS, the Comptroller General, or their designees the right to inspect, evaluate and audit books and other records and that these rights continue for a period of 10 years from the final date of the contract period or the date of audit completion, whichever is later. Language must be included to specify whether the applicant and the subcontractor have agreed that CMS or its designees may have direct access to the subcontractor’s records (e.g. on-site access to the subcontractor).
Contains language that the subcontractor (first tier, downstream, and related entities) will ensure that beneficiaries are not held liable for fees that are the responsibility of the MA contractor in accordance with 42 CFR 422.504(i)(3)(i).
Contains language that if the Applicant, upon becoming a MA contractor, delegates an activity or responsibility to the subcontractor (first tier, downstream, and related entities), that such activity or responsibility is in accordance to 42 CFR 504 (i) (3) and clearly indicates that any books, contracts, records, including medical records and documentation relating to the Part C program will be provided to either the contractor to provide to CMS or will be provided directly to CMS or its designees; and 2) may be revoked if CMS or the MA contractor determines the subcontractor (first tier, downstream, and related entities) has not performed satisfactorily. The subcontract may include remedies in lieu of revocation to address this requirement.
Contains language specifying that the Applicant, upon becoming a MA contractor, will monitor the performance of the subcontractor (first tier, downstream, and related entities) on an ongoing basis in accordance with 42 CFR 422.504 (i)(1) & (4).
D. Provide in HPMS, a completed “CMS Administrative/Management Delegated Contracting or Arrangement Matrix”.
1.11 Health Services Management & Delivery (For All CCP Applicants including RPPOs, and for PFFS & MSA Applicants offering a network)
A. In HPMS, complete the table below.
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH SERVICES MANAGEMENT (FOR CCP APPLICANTS, AND PFFS & MSA APPLICANTS OFFERING A NETWORK) |
YES |
NO |
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Note: This question is not applicable to PFFS or MSA non-network model applicants. |
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B. Provide in HPMS, completed HSD tables 1 through 5. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
1.12 Quality Improvement Program
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: QUALITY IMPROVEMENT PROGRAM (CCP & RPPOS ONLY) |
YES |
NO |
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1.13 Medicare Operations
1.13.1 Marketing
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MARKETING |
YES |
NO |
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1.13.2 Enrollment, Disenrollment, and Eligibility
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ENROLLMENT, DISENROLLMENT, AND ELIGIBILITY |
YES |
NO |
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Working Aged Membership
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: WORKING AGED MEMBERSHIP |
YES |
NO |
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1.13.4 Claims
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS |
YES |
NO |
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1.14 Minimum Enrollment
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MINIMUM ENROLLMENT |
YES |
NO |
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1.15 Communication between Medicare Advantage Plan and CMS
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMMUNICATION BETWEEN MEDICARE ADVANTAGE PLAN AND CMS |
YES |
NO |
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1.16 Grievances
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: GRIEVANCES |
YES |
NO |
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Note: A grievance is any complaint or dispute, other than one that 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. An enrollee or their representative 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 compliant 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.
1.17 Appeals
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: APPEALS |
YES |
NO |
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Date of receipt; Date of any notification; Disposition of request; and Date of disposition
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1.18 Health Insurance Portability and Accountability Act of 1996 (HIPAA) and CMS issued guidance 07/23/2007 and 8/28/2007; 2008 Call Letter
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) |
YES |
NO |
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In HPMS complete the table below;
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: |
YES |
NO |
1. Applicant agrees not to use an enrollee’s Social Security Number (SSN) or Medicare ID Number on the enrollee’s identification card. |
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C. Provide in HPMS a complete “Data Use Attestation”
1.19 Continuation Area
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTINUATION AREA |
YES |
NO |
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1.20 Medicare Advantage Certification
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MEDICARE ADVANTAGE CERTIFICATION |
YES |
NO |
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NOTE: Based on the type of application submission indicated by MAO once the Part C application is complete, applicant must complete a Part D application/module in HPMS. PFFS organizations have the option to offer Part D plans. MSAs are not allowed to offer Part D.
SECTION 2 REGIONAL PREFERRED PROVIDER ORGANIZATION (RPPO) APPLICANTS ONLY
Note: A RPPO applicant may apply as a signal 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
Allocation of CMS payments among the member organizations.
2.1 State licensure RPPO
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE RPPO |
YES |
NO |
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Provide in HPMS, a complete “CMS State Licensing Status for MA Regional PPO Table” for each MA Region.
Provide in HPMS, a signed” CMS State Licensure Attestation for MA Regional PPOs”
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 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.
2.2 Access Standards
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS STANDARDS |
YES |
NO |
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Provide in HPMS, access standards for the following specified provider types, including the percentage of beneficiaries that will fall within the standards and stated in terms of distance and time (___% of beneficiaries fall within xx miles/xx minutes of 2 Primary Care Providers):
Contracted Hospitals with Full Emergency Facilities
Contracted Primary Care Providers
Contracted Skilled Nursing Facilities
Contracted Home Health Agencies
Contracted Ambulatory Clinics
Contracted Providers of End Stage Renal Disease Services
Contracted Outpatient Laboratory and Diagnostic Services
Contracted Specialists in the following areas:
General Surgery
Otology/Laryngology/Rhinology
Anesthesiology
Cardiology
Dermatology
Gastroenterology
Internal Medicine
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Psychiatry/Mental Health
Pulmonary Disease
Urology
Chiropractic
Optometry
Podiatry
Provide in HPMS, a chart listing all counties (or other units of analysis as relied upon by applicant in establishing standards) and indicate whether each county meets or does not meet each contracted access standard for a contracted provider type.
Provide in HPMS, an access plan describing the applicants proposed mechanism for ensuring beneficiary access to the identified type(s) of provider(s) for each area in which the applicant does not meet its access standards through it contracted network. Access plans may include requests for essential hospital designations, facilitating enrollee access to non-contracted providers at preferred cost sharing levels, or other proposed mechanisms as approved by CMS.
2.3 Essential Hospital
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ESSENTIAL HOSPITAL |
YES |
NO |
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Provide in HPMS, a completed “CMS Essential Hospital Designation Table”.
Provide in HPMS, a completed “CMS Attestation Regarding Designation of Essential Hospitals”.
SECTION 3 PRIVATE FEE FOR SERVICE (PFFS) APPLICANTS ONLY
3.1 Access to Services
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS TO SERVICES |
YES |
NO |
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DROP DOWN BOX WITH
THE FOLLOWING SERVICES:
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Provide in HPMS, completed HSD tables 1 through 5 for network model PFFS plans. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
Provide in HPMS, a description on how the applicant will follow CMS’s national coverage decisions and written decision of carriers and intermediaries (LMRP) throughout the United States. [Refer to 42 CFR 422.101 (b)].
Provide in HPMS, a description on how applicant’s policies will ensure that health services are provided in culturally competent manner to enrollees of different backgrounds.
3.2 Claims Processing
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS PROCESSING |
YES |
NO |
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3.3 Payment Provisions (This section may be applicable to PFFS, MSA & MSA Demo Plans)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PAYMENT PROVISIONS |
YES |
NO |
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Note: For PFFS Plans only |
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Note: For PFFS Plans Only |
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Provide in HPMS, a completed Payment Reimbursement grid. (Note: Applicant can use CMS model payment guidance)
SECTION 4 MEDICAL SAVINGS ACCOUNTS (MSA) & MSA DEMO APPLICANTS ONLY
Note: MSA applicants must complete section four, in addition the applicant may have to complete questions in the “ Section 3: section three “Private Fee for Service” section of this application depending upon the type of delivery system that the applicant will offer under the MSA product.
Note: MSA plans cannot offer the Part D drug benefit.
Note: MSA Demonstration Addendum – If the applicant intends to participate in the MSA Demonstration, the Applicant must complete both sections 4 & 5.
General Administration/ Management
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: GENERAL ADMINISTRATION/MANAGEMENT |
YES |
NO |
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4.2 Access to Services (See Section 3.1 under PFFS)
4.3. Claims Systems ( See Section 3.2 under PFFS )
Payment Provisions ( See Section 3.3 under PFFS)
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SECTION 5 MSA DEMONSTRATION APPLICANTS ONLY
5.1 MSA Demonstration Addendum
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MSA DEMONSTRATION ADDENDUM |
YES |
NO |
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B. Provide in HPMS, the following:
Description of any differential in cost sharing for supplemental benefits from the standard Medicare A/B benefits and for in-network and out-of-network services.
Description of the preventive services that will have full or partial coverage before the deductible is met.
Figures on projected enrollment and the characteristics of beneficiaries who are most likely to enroll in the applicant’s plans (for example, what type of Medicare coverage do they currently have?).
Description of non-Medicare covered preventive services and whether or not any cost sharing for these services will apply to the plan deductible.
Description of the frequency of periodic deposits and how the applicant will address cases where the enrollee incurs high health costs early in the year.
Description on how the applicant will track enrollee usage of information provided on the cost and quality of providers. Be sure to include how you intend to track use of health services between those enrollees who utilize transparency information with those who do not.
Description on how the applicant will recover current-year deposit amounts for members who are disenrolled from the plan before the end of the calendar year.
PART 3 SERVICE AREA EXPANSION APPLICATIONS
Organizations that may use this application are HMOs; Local PPOs, State Licensed PSOs; PFFS, and MSA organizations.
SECTION 1 ALL MA APPLICANTS except RPPO’s
1.1 Contract Number in HPMS
Enter contract number in HPMS under the Contract/Management Module.
1.2 State Licensure (CCP, PFFS, & MSA Applicants Only)
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS. |
YES |
NO |
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Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 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.
1.3 Provider Contracts & Agreements
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR PROVIDER CONTRACTS & AGREEMENTS |
YES |
NO |
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4. Applicant has executed provider and supplier contracts in place to demonstrate access and availability of the requested service area. |
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5. Applicant agrees to make contracts and/or agreements available for CMS upon request. |
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Provide in HPMS a completed “CMS Provider Arrangements by County Table”. Applicant should insert the number of provider contract and/or agreements for each proposed service area or distinctive system(s) applicant.
Provide in HPMS a sample copy of each category of provider contract(s) and agreement(s) between the applicant and its primary health care contractors.
Provide in HPMS a sample copy of each subcontract between medical groups, IPAs, PHO, etc. including their subcontracting providers.
Provide in HPMS a completed, “Provider Participation Contracts and/or Agreements”, a crosswalk of CMS regulations to provider contracts and/or agreements. Prepare a table for each contracted and subcontracted provider.
Note: As part of the application process, applicants will be instructed to provide a sample of provider contract signatures. Applicants will receive further instructions by their CMS application reviewer.
1.4 Contracts for Administrative & Management Services
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE & MANAGEMENT SERVICES |
YES |
NO |
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B. In HPMS, complete the table below.
DELEGATED BUSINESS FUNCTION |
All SUBCONTRACTOR(S) , including downstream. |
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C. Provide in HPMS executed delegated administrative services/management contracts or letters of agreement for each contractor or subcontractor (first tier, downstream, and related entities) identified in the chart (Section 1.4.B) above that:
Clearly identify the parties to the contract (or letter of agreement).
Describes each of the specific functions (health and/or administrative) that are now or will be delegated to medical groups, IPAs, or other intermediate entities.
Describes how the applicant will remain accountable for any functions or responsibilities that are delegated to other entities.
Describes how the applicant will oversee, and formally evaluate delegated entities.
Describes the applicant's relationships to related entities, contractors and sub-contractors with regard to provision of health and/or administrative services specific to the Medicare product.
Contains language clearly indicating that the delegated entity, contractor, or subcontractor (first tier, downstream, and related entities) has agreed to perform the health and/or administrative service, and clauses requiring their activities be consistent and comply with the Applicant’s contractual obligations.
Are signed by a representative of each party with legal authority to bind the entity.
Contains language obligating the contractor or subcontractor (first tier, downstream, and related entities) to abide by all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 422 (504)(i)(4)(v).
Contains language obligating the subcontractor (first tier, downstream, and related entities)to abide by State and Federal privacy and security requirements, including the confidentiality and security provisions stated in the regulations for this program at 42 CFR §422.504(a)(13).
Contains language ensuring that the contractor or subcontractor (first tier, downstream, and related entities) will make its books and other records including medical records and documentation involving transactions related to CMS’ contract with the MA organization available in accordance with 42 CFR 422.504 (i) (2). Generally stated these regulations give HHS, the Comptroller General, or their designees the right to inspect, evaluate and audit books and other records and that these rights continue for a period of 10 years from the final date of the contract period or the date of audit completion, whichever is later. Language must be included to specify whether the applicant and the subcontractor have agreed that CMS or its designees may have direct access to the subcontractor’s records (e.g. on-site access to the subcontractor).
Contains language that the subcontractor (first tier, downstream, and related entities) will ensure that beneficiaries are not held liable for fees that are the responsibility of the MA contractor in accordance with 42 CFR 422.504(i)(3)(i).
Contains language that if the Applicant, upon becoming a MA contractor, delegates an activity or responsibility to the subcontractor (first tier, downstream, and related entities), that such activity or responsibility is in accordance to 42 CFR 504 (i) (3) and clearly indicates that any books, contracts, records, including medical records and documentation relating to the Part C program will be provided to either the contractor to provide to CMS or will be provided directly to CMS or its designees; and 2) may be revoked if CMS or the MA contractor determines the subcontractor (first tier, downstream, and related entities) has not performed satisfactorily. The subcontract may include remedies in lieu of revocation to address this requirement.
Contains language specifying that the Applicant, upon becoming a MA contractor, will monitor the performance of the subcontractor (first tier, downstream, and related entities) on an ongoing basis in accordance with 42 CFR 422.504 (i)(1) & (4).
D. Provide in HPMS, a completed “CMS Administrative/Management Delegated Contracting or Arrangement Matrix”.
1.5 Health Services Delivery (HSD)
A. In HPMS, complete the table below.
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR HEALTH SERVICES DELIVERY |
YES |
NO |
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B. Provide in HPMS and as appendices, HSD tables 1 through 5. Applicants offering multiple benefit plans must submit separate tables for each county and each plan. Only one HSD table is needed for different plans that have the same network and service area.
1.6 Service Area
A. In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area you plan to serve.
B. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING QUALIFICATIONS FOR SERVICE AREA. |
YES |
NO |
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C. Provide as an attachment detailed maps of the requested service area showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. Maps should indicate contracted ambulatory and hospital providers, and mean travel times.
For each county in the requested service area, there should be four separate maps. The first map should reflect the boundaries of the county as well as main traffic arteries (highways, interstates) and any physical barriers such as mountains or rivers. This map should include contracted ambulatory (outpatient-stand alone) facilities with the mean travel times to each location. The second map should indicate all contracted hospitals, skilled nursing facilities, rehabilitation facilities and psychiatric hospitals. Each facility type should be delineated as a separate color or symbol. The third map should contain all contracted primary care providers. The fourth map should contain all contracted specialty providers. Each specilaity type should be delineated as a separate color or symbol.
note: RPPO applicants geographic maps should be defined by rural and urban areas (include borders) that demonstrate the locations of all contracted providers in relation to the beneficiaries in those areas.
1.7. Continuation Area
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTINUATION AREA |
YES |
NO |
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SECTION 2 SERVICE AREA EXPANSIONS FOR RPPO APPLICANTS ONLY
2.1 State licensure RPPO
A. In HPMS, complete the table below:
RESPOND “YES” OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE RPPO |
YES |
NO |
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3. Applicant meets State-specified standards applicable to MA RPPO plans and is authorized by the state to accept prepaid capitation for providing and arranging or paying for comprehensive health care services to be offered under the MA contract.
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4. Applicant is currently under some type of supervision (i.e., corrective action plan, special monitoring, etc…) by the State licensing authority in ANY state. This means that the applicant has to disclose actins to any state against the same legal entity as the applicant.
If “Yes”, provide in HPMS and as an attachment, an explanation of the specific actions taken by the State licensure regulator.
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5. Applicant conducts business as “doing business as “ (dba) or uses a name different than the name shown on it Articles of Incorporation.
If “Yes”, provide in HPMS and as an attachment a copy of the State approval for the dba. |
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B. Provide in HMPS, a complete “CMS State Licensing Status for MA Regional PPOs Table” for the SAE MA Region.
C. Provide in HPMS, a signed “CMS State Licensure Attestation for MA Regional PPOs.
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 422.402 state that MA standards supersede State law or regulation with respect to MA plans other thank licensing laws and laws relating to plan solvency.
NOTE: For states such as Puerto Rico whose licenses renew after June 1, the applicant is required to submit the new license in order to operate as an MA or MA-PD.
2.2 Access Standards
A. In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS STANDARDS |
YES |
NO |
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Provide in HPMS, access standards for the following specified provider types, including the percentage of beneficiaries that will fall within the standards and stated in terms of distance and time (___% of beneficiaries fall within xx miles/xx minutes of 2 Primary Care Providers):
Contracted Hospitals with Full Emergency Facilities
Contracted Primary Care Providers
Contracted Skilled Nursing Facilities
Contracted Home Health Agencies
Contracted Ambulatory Clinics
Contracted Providers of End Stage Renal Disease Services
Contracted Outpatient Laboratory and Diagnostic Services
Contracted Specialists in the following areas:
General Surgery
Otology/Laryngology/Rhinology
Anesthesiology
Cardiology
Dermatology
Gastroenterology
Internal Medicine
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Psychiatry/Mental Health
Pulmonary Disease
Urology
Chiropractic
Optometry
Podiatry
Provide in HPMS, a chart listing all counties (or other units of analysis as relied upon by applicant in establishing standards) and indicate whether each county meets or does not meet each contracted access standard for a contracted provider type.
Provide in HPMS, an access plan describing the applicants proposed mechanism for ensuring beneficiary access to the identified type(s) of provider(s) for each are in which the applicant does not meet its access standards through it contracted network. Access plans may include requests for essential hospital designations, facilitating enrollee access to non-contracted providers at preferred cost sharing levels, or other proposed mechanisms as approved by CMS.
2.3 Essential Hospital
In HPMS, complete the table below:
RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ESSENTIAL HOSPITAL |
YES |
NO |
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Provide in HPMS, a completed “CMS Essential Hospital Designation Table”.
Provide in HPMS, a completed “CMS Attestation Regarding Designation of Essential Hospitals”.
PART 4 SOLICITATIONS FOR SPECIAL NEEDS PLAN PROPOSAL
Beginning with the 2010 contract year all Medicare Advantage (MA) Special Needs Plans (SNP) must meet the requirements set forth under the Medicare Improvements for Patients and Providers Act of 2008, P.L.110-275 (MIPPA). MIPPA extended the authority for SNPs through the end of 2010 and added significant new provisions for MAs that want to apply or continue to offer SNPs. MIPPA placed a moratorium to designate other plans as SNPs, beginning January 1, 2010 and ending December 31, 2010. This precludes CMS from approving “disproportionate share” SNPs. For the 2010 MA contract year, an applicant requesting to offer a new SNP will only be approved as an exclusive SNP. The remainder of this introductory section provides an overview of the MIPPA requirements for SNPs which are effective January 1, 2010.
Specific Requirements for Dual-eligible SNPs: All applicants who want to offer a new or expand the service area of an existing dual-eligible SNP must have a contract with the State Medicaid agency covering the MA SNP contracting period. Under the contract, the MA organization must retain responsibility for providing, or arranging for benefits to be provided, for individuals entitled to receive medical assistance under Title XIX. Such benefits may include long-term care services consistent with State policy.
MA organizations with an existing dual-eligible SNP without a State Medicaid agency contract may continue to operate with out a State Medicaid agency contract through 2010, provided all other statutory requirements are met, i.e., care management and quality improvement program requirements. However, they may not expand their service area for the 2010 MA contract year. After 2010, all existing dual-eligible SNPs without a State Medicaid agency contract will be required to have a State Medicaid agency contract for the 2011 MA contract year. In addition, the statute specifically made it clear that State Medicaid agencies are not required to enter into contracts with MA organizations for dual-eligible SNPs.
Dual-eligible SNPs must provide each prospective enrollee, prior to enrollment, with a comprehensive written statement of benefits and cost-sharing protections under the SNP as compared to protections under the relevant State Medicaid plan and limits the dual-eligible SNP from imposing cost-sharing requirements on dual-eligible individuals that would exceed the amounts permitted under the State Medicaid plan if the individual were not enrolled in the dual-eligible SNP. This requirement is to assist a prospective dual-eligible enrollee to determine if he/she will receive any value from enrolling in the dual-eligible SNP that is not already available under the State Medicaid program.
Specific Requirements for Institutional SNPs: Institutional SNPs that enroll individuals living in the community but requiring an institutional level of care are required to use the State assessment tool to determine the need for institutional level of care. The assessment must be performed by an entity other than the MA organization offering the SNP.
Specific Requirements for Severe or Disabling Chronic Condition SNPs: A severe or disabling chronic condition SNP is now defined as a special needs plan that exclusively serves an individual who has a severe or disabling chronic condition and must determine that the individual has one or more co-morbid and medically complex chronic conditions that are substantially disabling or life-threatening, has a high risk of hospitalization or other significant adverse health outcomes, and requires specialized delivery systems across domains of care.
As directed by MIPPA, CMS is in the process of convening a clinical advisors panel to determine the conditions that meet the definition of severe and disabling chronic conditions. CMS will issue guidance after the conclusion of the panel findings.
Requirements for All (both new and existing) SNPs:
Enrollment Requirements: Both existing and new SNPs can only enroll individuals who meet the statutory definition of special needs individual for the specific SNP. Applicants should refer to the definition section below to assure that their proposal will comply with enrolling only those beneficiaries who meet the statutory definition of special needs individual for their specific type SNP.
Care Management Requirements: All SNPs are required to implement an evidence-based model of care having two explicit components. The first component is an appropriate network of providers and specialists to meet the specialized needs of the SNP target population. The second component is a battery of care management services that includes 1) a comprehensive initial assessment and annual reassessments, 2) an individualized plan of care having goals and measurable outcomes, and 3) an interdisciplinary team to manage care. Listed below are examples that illustrate a variety of ways SNPs have developed and implemented their models of care.
1. SNPs must have appropriate staff trained on the SNP model of care to coordinate and/or deliver standard and add-on services and benefits. One SNP has chosen to contract with a provider network to deliver care in community health clinics while another SNP has hired practitioners to deliver care in the home setting.
2. SNPs must coordinate the delivery of services and benefits through integrated systems of communication among plan personnel, providers, and beneficiaries. One SNP coordinates care through a telephonic link among all stakeholders and a second SNP coordinates care through an electronic system using web-based records and electronic mail exclusively accessed by the plan, network providers, and beneficiaries.
3. SNPs must coordinate the delivery of add-on benefits and services that meet the specific needs of their most vulnerable beneficiaries. A dual-eligible SNP was required by their state contract to provide state-identified services such as transportation to physician visits while an institutional SNP chose to facilitate hospice care for its beneficiaries near the end of life.
4. SNPs must coordinate care through an interdisciplinary team. One SNP team was composed of primary care physicians, nurses, social workers, and appropriate disease management specialists while another SNP team had geriatric specialists, nurse practitioners, clinical pharmacists, and nurse educators to efficaciously meet their beneficiaries’ needs.
Quality Reporting Requirements: All SNPs are required to collect, analyze, and report data as part of the SNP’s quality improvement program to measure health outcomes and other indices of quality at the plan level with respect to the care management model of care.
As an MA plan, each SNP must implement a documented quality improvement program for which all information is available for submission to CMS or for review during monitoring visits. The focus of the SNP quality improvement program should be the monitoring and evaluation of the performance of its model of care. The program should be executed as a three-tier system of performance improvement.
The first tier consists of data on quality and outcomes that is collected and analyzed to enable beneficiaries to compare and select from among health coverage options. In calendar year (CY) 2008, CMS required the submission of thirteen HEDIS measures and three structure and process measures to pilot the development of comparative measures to facilitate beneficiary choice. We continue to work on this initiative and will issue guidance to SNPs on collecting comparative measures for submission using CMS required tools in CY 2009.
The second tier of the quality improvement program supplants § 422.152(b) with § 422.152(g) for SNPs based on the statutory requirement that SNPs collect, analyze, and report data that measures the performance of their plan-specific model of care. This new rule establishes CMS requirements for measuring essential components of the model of care using a variety of plan-determined methodologies such as claims data, record reviews, administrative data, clinical outcomes, and other existing valid and reliable measures (ACOVE, MDS, HEDIS, CAHPS, HOS, OASIS, etc.) at the plan level.
Specifically, SNPs should collect, analyze, and be prepared to report data for its performance on: access to care; improvement in beneficiary health status; care management through its staffing structure and processes; assessment and stratification of health risk; care management through an individualized plan of care; provision of specialized clinical expertise targeting its special needs population; the coordination and delivery of services and benefits through transitions across settings and providers; the coordination and delivery of extra services and benefits that meet the needs of the most vulnerable beneficiaries; the use of evidence-based practices and/or nationally recognized clinical protocols; and the application of integrated systems of communication.
Each SNP must coordinate the systematic collection of data using indicators that are objective, clearly defined, and based on measures having established validity and reliability. Indicators should be selected from a variety of quality and outcome measurement domains such as functional status, care transitioning, disease management, behavioral health, medication management, personal and environmental safety, beneficiary involvement and satisfaction, and family and caregiver support. SNPs must document all aspects of the quality improvement program including data collection and analysis, actions taken to improve the performance of the model of care, and the participation of the interdisciplinary team members and network providers in quality improvement activities.
CMS is developing the third tier of the quality improvement program which is the required reporting of monitoring data. The monitoring data will consist of a prescribed sample of data that SNPs will already be collecting in tier two to measure the performance of their model of care. We will draw from a pool of measures across several service delivery domains, and, whenever possible, use valid measures that SNPs have reported they currently collect. We are also soliciting comments from the public regarding the types of monitoring data CMS should require SNPs to submit. We will issue guidance on the requirement to report monitoring data and the collection methodology after reviewing the public comments and completing development of the initiative for implementation in calendar year 2010.
Definitions:
Full Benefit Dual Eligible (FBDE aka Medicaid only): An individual who does not meet the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either categorically or through optional coverage groups such as medically needy, or special income levels for institutionalized, or home and community-based waivers.
Qualified Medicare Beneficiary (QMB): An individual entitled to Medicare Part A, has income at the 100% Federal Poverty Level (FPL) or less, and resources that do not exceed twice the SSI limit. This individual is eligible for Medicaid payment of Medicare Part B premium, deductibles, co-insurance and co-pays, (except for Part D).
Qualified Medicare Beneficiary Plus (QMB+): An individual who meets standards for QMB eligibility and also meets criteria for full Medicaid benefits in the State. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or through spending down excess income to the Medically Needy level.
Specified Low-Income Medicare Beneficiary (SLMB): An individual entitled to Medicare Part A, has income that exceeds 100% FPL but less then 120% FPL, and resources do not exceed twice the SSI limit. A SLMB is eligible for Medicaid payment of the Medicare Part B premium.
Specified Low-Income Medicare Beneficiary Plus (SLMB+): An individual who meets the standards for SLMB eligibility, but who also meets the criteria for full State Medicaid benefits. Such individuals are entitled to payment of the Medicare Part B premium, as well as full State Medicaid benefits. These individuals often qualify for Medicaid by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.
Qualified Disabled and Working Individual (QDWI): An individual who has lost Medicare Part A benefits due to a return to work, but is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. QDWIs are eligible only for Medicaid payment of the Part A premium.
Qualifying Individual (QI): An individual entitled to Medicare Part A, has income at least 120% FPL but less than 135% FPL, and resources that do not exceed twice the SSI limit, and not otherwise eligible for Medicaid benefits. This individual is eligible for Medicaid payment of Medicare Part B premium.
All duals: A SNP that has a State Medicaid agency contract to enroll all categories of Medicaid eligible individuals, who are also Medicare entitled, e.g., FBDE, QMB, QMB+, SLMB, SLMB+, QI and QDWI.
Full duals: A SNP that has a State Medicaid agency contract to enroll Medicaid eligible individuals, who are also Medicare entitled, in the following categories: 1) FBDE, 2) QMB+ and 3) SLMB+.
Zero cost share: A SNP that has a State Medicaid agency contract to enroll Medicaid eligible individuals, who are also Medicare entitled, in the following categories: 1) QMB, 2) QMB+ and 3) any other dual eligible beneficiaries for which the State holds harmless for Part A and Part B cost sharing except Part D.
Medicaid Subset: A SNP that has a State Medicaid agency contract to enroll Medicaid eligible individuals, who are also Medicare entitled, that targets a defined population in order to coordinate services between the Medicare and Medicaid programs. Any enrollment limitations for Medicare beneficiaries under this SNP must parallel any enrollment limitations under the Medicaid program, including the structure and care delivery patterns of the Medicaid program. For example, if a State Medicaid Agency contracts with a plan for a Medicaid wraparound package for certain dual eligible (such as disabled individuals), an MA organization may establish a SNP that limits enrollment to that same subset of dual eligibles. Further, the SNP must provide documentation to CMS regarding their contract with the State Medicaid agency. If applicable, this would include verification as to whether this subset will have zero cost sharing for Medicare Parts A and B for enrolled dual eligible beneficiaries.
Institutional SNP: A SNP that enrolls eligible individuals who continuously reside or are expected to continuously reside for 90 days or longer in a long-term care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); and/or an inpatient psychiatric facility. An institutional SNP to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the specific LTC facility/ies.
Institutional equivalent SNP – (living in the community): An institutional SNP that enrolls eligible individuals living in the community but requiring an institutional level of care based on the State assessment. The assessment must be performed by an entity other than the organization offering the SNP. This type of SNP may restrict enrollment to individuals that reside in a contracted assisted living facility (ALF) as this may be necessary in order to ensure uniform delivery of specialized care.
SNP Proposal Applications Instructions
Initial (new) SNP
An applicant, including an existing MA contractor, offering a new SNP must submit their SNP proposal by completing the HPMS SNP Proposal Application template. A SNP proposal application must be completed for each SNP type to be offered by the MA.
All applicants requesting to offer a dual-eligible SNP must have a State Medicaid Agency contract or is working with the State Medicaid Agency toward that goal. A dual-eligible SNP
must have a State Medicaid Agency contract in place prior to the contract year and the contract must cover the entire contract year to offer a MA SNP for the MA contract year.
In general, CMS recommends and encourages MA 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. Also, other associated MA and Part D applications must also be provided. Applicants must read HPMS notices and visit the CMS web site periodically to stay informed about new or revised guidance documents.
SNP Service Area Expansion (SAE)
An MA contractor, who wants to expand the service area of the SNP, must adhere to the same requirements for submission of an initial SNP proposal application.
A dual-eligible SNP that does not have a State Medicaid Agency contract cannot expand the service area of the existing SNP. If the MA dual-eligible SNP that does not have a State Medicaid Agency contract intends to offer the dual-eligible SNP after 2010, it should take immediate actions to initiate a contract with the State Medicaid Agency.
Existing SNP with no change
An MA contractor, who offers an existing SNP must complete the 1) “Care Management Requirements” and 2) “Quality Reporting Requirements” in the HPMS SNP Proposal Application template.
SNP Proposal Applications
In HPMS, complete the table below:
SNP Proposal Applications |
Yes |
No |
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Applicant is applying to offer a new dual-eligible SNP. |
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XX |
How many new dual-eligible SNPs? |
XX |
XX |
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Applicant is applying to offer a new severe or disabling chronic condition SNP. |
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XX |
How many new severe or disabling chronic condition SNPs? |
XX |
XX |
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Applicant is applying to offer a new institutional SNP. |
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XX |
How many new severe or disabling chronic condition SNPs? |
XX |
XX |
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Applicant is applying to expand an existing dual-eligible SNP. |
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XX |
Applicant is applying to expand an existing severe or disabling chronic condition SNP. |
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XX |
Applicant is applying to expand an existing institutional SNP. |
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XX |
New and Expansion of Existing Dual-eligible SNPs Proposal Applications
In HPMS, complete the table below:
New and Expansion of Existing Dual-eligible SNPs Proposal Applications |
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SNP Service Area: |
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Provide the service area (State and County codes) for SNP proposal. |
XX |
XX |
XX |
Service area covers more than one State.
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XX |
Provide the names of the States. |
XX |
XX |
XX |
State Medicaid Agency Contracts: |
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Applicant has an existing contract with the State Medicaid Agency(ies) that covers the SNP service area for the current application year.
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XX |
Applicant has contacted the State Medicaid Agency(ies) and initiated negotiation of a contract.
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XX |
Applicant will have a signed State Medicaid Agency(ies) contract by September 1 of the current application year.
Note: CMS will not approve an applicant to offer a dual-eligible SNP who does not have a signed State Medicaid Agency(ies) contract by September 1 of the current application year to offer a dual-eligible SNP. |
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XX |
Provide copy of the signed State Medicaid Agency(ies) contract. |
XX |
XX |
XX |
Provide the State Medicaid contract begin date. |
XX |
XX |
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Provide the State Medicaid Agency(ies) contract end date. |
XX |
XX |
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Does the State Medicaid Agency(ies) contract period extend through the CMS MA contract period?
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XX |
If the State Medicaid Agency(ies) contract period does not extend through the CMS MA contract period, has the applicant contacted the State Medicaid Agency(ies) and initiated negotiation of a contract extension?
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XX |
Provide the State Medicaid Agency(ies) contract approved service area. |
XX |
XX |
XX |
State Medicaid Agency(ies) contract enrolled population: |
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Applicant has an approved State Medicaid Agency(ies) contract to cover all dual-eligible enrollment categories (QMB, QMB+, SLMB, SLMB+, QDWI, QI, and FBDE). See definition section for the description of these categories. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “full dual-eligible” enrollment category (QMB+, SLMB+ and other full benefit dual-eligible). |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “zero cost sharing” enrollment category (QMB, QMB+ and any other dual-eligible category where the State covers all cost sharing). |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “other full benefit dual-eligible”, also known as “Medicaid only,” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Qualified Medicare Beneficiary (QMB) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Qualified Medicare Beneficiary Plus(QMB+) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Specified Low-income Medicare Beneficiary (SLMB) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Specified Low-income Medicare Beneficiary Plus (SLMB+) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Qualifying Individual (QI) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “Qualified Disabled and Working Individual (QDWI) dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “dual-eligible who are institutionalized dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover the “dual-eligible who are institutional equivalent dual-eligible” enrollment category. |
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XX |
Applicant has an approved State Medicaid Agency(ies) contract to cover a Medicaid Subset enrollment category other than those listed above.
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XX |
Provide a description of the Medicaid Subset for other than what is listed above. |
XX |
XX |
XX |
Does the State Medicaid Agency(ies) contract include the Medicaid benefits covered in the SNP?
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XX |
Provide a description of the Medicaid benefits covered in the State Medicaid contract. |
XX |
XX |
XX |
Does the State Medicaid Agency(ies) contract includes the cost-sharing protections covered in the SNP?
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Provide a description of the cost-sharing protections covered in the State Medicaid contract. |
XX |
XX |
XX |
Does the State Medicaid Agency(ies) contract includes the identification and sharing of information on Medicaid provider participation?
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Provide a description of the identification and sharing of information on Medicaid provider participation covered in the State Medicaid contract. |
XX |
XX |
XX |
Does the State Medicaid Agency(ies) contract includes the MA organization’s responsibilities, including financial obligations, to provide or arrange for Medicaid benefits?
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Provide a description of the MA organization’s responsibilities, including financial obligations, to provide or arrange for Medicaid benefits covered in the State Medicaid contract. |
XX |
XX |
XX |
Provide the name of the contact individual at the State Medicaid Agency(ies). |
XX |
XX |
XX |
Provide the address of the State Medicaid Agency contact person. |
XX |
XX |
XX |
Provide the phone number of the State Medicaid Agency contact person. |
XX |
XX |
XX |
Provide the e-mail address of the State Medicaid Agency contact person. |
XX |
XX |
XX |
Does the applicant have a process to verify Medicaid eligibility of individuals through the State? |
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XX |
Provide a description of the process to verify Medicaid eligibility of individuals through the State. |
XX |
XX |
XX |
Does the applicant have a process to coordinate Medicare and Medicaid services for dual-eligible individuals? |
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Provide a description of the process. |
XX |
XX |
XX |
New and Expansion of Existing Severe or Disabling Chronic Condition SNPs Proposal Applications
In HPMS, complete the table below:
New and Expansion of Existing Severe or Disabling Chronic Condition SNPs Proposal Applications |
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SNP Service Area: |
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Provide the service area (State and County codes) for SNP proposal. |
XX |
XX |
XX |
Does the service area cover more than one State?
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XX |
Provide the names of the States. |
XX |
XX |
XX |
Severe or disabling chronic conditions: |
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Applicant will offer a chronic condition SNP covering one or more of the following severe or disabling chronic conditions:
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XX |
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XX |
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XX |
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XX |
New and Expansion of Existing Institutional SNPs Proposal Applications
In HPMS, complete the table below:
New and Expansion of Existing Institutional SNPs Proposal Applications |
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SNP Service Area: |
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Provide the service area (State and County codes) for SNP proposal. |
XX |
XX |
XX |
Does the service area cover more than one State?
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XX |
Provide the names of the States. |
XX |
XX |
XX |
Will the applicant/SNP only enroll individuals residing in institutions? |
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XX |
Will the applicant/SNP only enroll individuals who are institutional equivalents residing in the community? |
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XX |
Will the applicant/SNP enroll individuals residing in institutions and institutional equivalents living in the community? |
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XX |
SNPs enrolling individuals residing in institutions |
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Will the applicant/SNP enroll only individuals residing in a long term care facility (SNF) under contract with or owned by the organization offering the SNP? |
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XX |
Provide a list of contracted long-term care facilities. |
XX |
XX |
XX |
Is the applicant/SNPs enrolling individuals who are institutional equivalents residing in the community |
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XX |
Provide a list of assisted-living facilities (if applicant/SNP is contracting with ALFs) |
XX |
XX |
XX |
Does the applicant/SNP own or have executed contracts with each of the ALFs on the list? |
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XX |
Does the applicant/SNP use the State assessment tool to assess level of care (LOC) for each institutional equivalent beneficiary? |
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XX |
Provide the State LOC assessment tool. |
XX |
XX |
XX |
Provide the url for the State LOC assessment tool if accessible on the State website. |
XX |
XX |
XX |
Does the SNP use an unrelated third party entity to perform the LOC assessment? |
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XX |
Provide the name of the entity(ies) performing the LOC assessment. |
XX |
XX |
XX |
Provide the address of the entity(ies) performing the LOC assessment. |
XX |
XX |
XX |
ESRD Waiver Requests
In HPMS, complete the table below:
ESRD Waiver Requests |
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Is the applicant requesting an ESRD waiver requests? |
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XX |
Provide a description of how it intends to serve the unique needs of the ESRD enrollees. |
XX |
XX |
XX |
Provide a list of the contracted dialysis facility(ies). |
XX |
XX |
XX |
Provide a list of the contracted transplant facility(ies). |
XX |
XX |
XX |
Provide a description of any additional service(s) provided to members with ESRD. |
XX |
XX |
XX |
Provide a description of the interdisciplinary care team coordinator role in the assessment and delivery of services needed by members with ESRD. |
XX |
XX |
XX |
SNP Care Management Requirements
In HPMS, complete the table below:
SNP Care Management Requirements (All)
Respond “Yes” or “No” to the following statements: |
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Targeted Special Needs Individuals |
Yes |
No |
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Applicant has a model of care to manage the delivery of specialized services and benefits to dual-eligible special needs individuals. |
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XX |
Applicant has a model of care to manage the delivery of specialized services and benefits to institutionalized or institutional equivalent special needs individuals. |
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XX |
Applicant has a model of care to manage the delivery of specialized services and benefits to special needs individuals having medically complex or multiple chronic conditions. |
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XX |
Applicant has a model of care to manage the delivery of specialized services and benefits to special needs individuals having end-stage renal disease. |
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XX |
Applicant’s model of care manages the delivery of specialized services and benefits to vulnerable special needs individuals who are frail, disabled, or near the end-of-life. |
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XX |
Goals |
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Applicant has written care management policies, procedures, and systems to assure access to medical services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure access to mental health services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure access to social services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure access to affordable quality care. |
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XX |
Applicant has written care management policies, procedures, and systems to assure coordination of care through a central point of contact. |
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XX |
Applicant has written care management policies, procedures, and systems to assure seamless transitions across healthcare settings, care providers, and health services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure access to preventive health services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure appropriate utilization of services. |
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XX |
Applicant has written care management policies, procedures, and systems to assure access to continuous care across the life cycle. |
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XX |
Applicant has written care management policies, procedures, and systems to assure cost-effective health services delivery. |
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XX |
Applicant has written care management policies, procedures, and systems to reduce hospitalization and nursing facility placement. |
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XX |
Applicant has written care management policies, procedures, and systems to improve beneficiary health status through improved independence and self-management. |
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XX |
Applicant has written care management policies, procedures, and systems to improve beneficiary health status through improved mobility and functional status. |
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XX |
Applicant has written care management policies, procedures, and systems to improve beneficiary health status through improved pain management. |
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XX |
Applicant has written care management policies, procedures, and systems to improve beneficiary health status through improved quality of life perception. |
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XX |
Applicant has written care management policies, procedures, and systems to improve beneficiary health status through improved satisfaction with health status and healthcare services. |
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XX |
Staff Structure and Roles |
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Applicant has appropriate staff to coordinate benefits, plan information, and data collection and analysis for beneficiaries, network providers, and the public. Staff include some or all of the following:
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
Applicant assures that staff coordinates benefits, plan information, and data collection and analysis for beneficiaries, network providers, and the public by performing tasks including some or all of the following:
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
Applicant has appropriate staff to perform care management and coordination of services and benefits. These staff include some or all of the following:
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
Applicant assures that care management staff performs duties including some or all of the following:
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
Applicant has appropriate staff to perform administrative and clinical oversight duties. These staff include some or all of the following:
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XX |
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XX |
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XX |
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XX |
Applicant assures that staff effectively performs administrative and clinical oversight duties. These duties include some or all of the following:
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XX |
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XX |
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XX |
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XX |
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XX |
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XX |
Interdisciplinary Care Team |
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Applicant assigns each beneficiary to an interdisciplinary care team composed of primary, ancillary, and specialty care providers. Members of the interdisciplinary care team include some or all of the following:
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Applicant assures that the interdisciplinary care team works together to manage beneficiary care by performing duties including some or all of the following:
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Provider Network |
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Applicant has a network of providers and facilities having specialized clinical expertise pertinent to the targeted special needs population. The provider and facility network delivers services beyond the scope of the interdisciplinary team including some or all of the following:
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Applicant assures that the provider and facility network having specialized clinical expertise pertinent to the targeted special needs population delivers services beyond the scope of the interdisciplinary team. Specialized clinical experts’ duties include some or all of the following:
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Applicant has a process to coordinate the delivery of standard services and benefits through a provider and facility network having clinical expertise pertinent to the targeted special needs population. The process includes some or all of the following:
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Applicant has policies, procedures, and a system to coordinate the delivery of care across all healthcare settings, providers, and services to assure continuity of care. The system includes some or all of the following:
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Applicant assures its providers deliver evidence-based services in accordance with nationally recognized clinical protocols and guidelines when available (see the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse at http://www.guideline.gov/). Assurance includes some or all of the following:
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Applicant has policies, procedures, and a system to coordinate the delivery of add-on benefits and services that meet the specialized needs of the most vulnerable including frail/disabled beneficiaries and beneficiaries near the end of life. The system includes some or all of the following:
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Model of Care Training |
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Applicant has appropriate staff (employed, contracted, or non-contracted) trained on the model of care to coordinate and/or deliver all services and benefits including some or all of the following:
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Applicant has a training strategy that uses a variety of methods including some or all of the following:
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Health Risk Assessment |
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Applicant has written policies, procedures, and a system to coordinate a comprehensive initial health risk assessment of the medical, functional, cognitive, and psychosocial status as well as annual health risk reassessments of each beneficiary. The system includes some or all of the following:
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Applicant has a process to develop or select and utilize a comprehensive risk assessment tool that will be reviewed during oversight activities. The process includes some or all of the following:
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Provide a copy of the comprehensive health risk assessment tool. |
XX |
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Applicant has a process to stratify health risks and develop a care management plan that mitigates those risks. The process includes some or all of the following:
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Individualized Care Plan |
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Applicant has written policies, procedures, and a system to assure that the interdisciplinary care team develops and implements a comprehensive individualized plan of care for each beneficiary. The system includes some or all of the following:
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Applicant has a written process to facilitate beneficiary/caregiver participation in care planning when feasible. The process includes some or all of the following:
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Communication |
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Applicant has written policies and procedures to coordinate the delivery of services and benefits through integrated systems of communication among plan personnel, providers, and beneficiaries. These systems include some or all of the following:
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XX |
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Applicant has written policies, procedures, and a system to coordinate communication among the interdisciplinary care team. The system includes some or all of the following:
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Performance and Health Outcomes Measurement |
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Applicant has written policies, procedures, and a system to collect and analyze data to evaluate the effectiveness of its model of care. |
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Applicant collects data from a variety of sources including some or all of the following:
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Applicant collects data using a variety or methodologies including some or all of the following:
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Applicant analyzes health indicators and performance data using a variety of mechanisms including some or all of the following:
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Applicant takes actions to improve the model of care including some or all of the following:
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Applicant collects and analyzes data that demonstrates beneficiaries have access to eligible services and benefits, and acts to improve deficiencies that are identified. |
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Applicant collects and analyzes data that demonstrates beneficiaries have improved health status, and acts to improve deficiencies that are identified. |
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Applicant collects and analyzes data on service delivery processes and outcomes, and acts to improve deficiencies that are identified. |
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Applicant collects and analyzes data on chronic condition management using evidence-based guidelines, and acts to improve deficiencies that are identified. |
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XX |
Applicant collects and analyzes data on the utilization of evidence-based guidelines by the interdisciplinary team and provider network, and acts to improve deficiencies that are identified. |
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Applicant collects and analyzes data demonstrating the participation of beneficiaries and interdisciplinary care team members in care planning, and acts to improve deficiencies that are identified. The data includes some or all of the following:
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Applicant collects and analyzes data related to add-on services and benefits including beneficiary utilization and/or satisfaction with such services and benefits, and acts to improve deficiencies that are identified. |
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Applicant collects and analyzes data on beneficiary utilization of communication mechanisms (e.g., call centers, complaint logs, etc.), and acts to improve deficiencies that are identified. |
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Applicant has written policies, procedures, and a system to submit required public reporting data that inform stakeholders about the plan’s performance as requested by CMS. These data include some or all of the following:
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Applicant has written policies, procedures, and a system to submit required reporting data that monitors the plan’s performance as requested by CMS. These data include some or all of the following:
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SNP Quality Improvement Program Requirements
In HPMS, complete the table below:
SNP Quality Improvement Program Requirements |
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Applicant has policies, procedures, and a system for conducting a quality improvement program? |
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Provide a written description of the quality improvement program. |
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Applicant collects, analyzes, and reports data that measure health outcomes and indices of quality pertaining to its targeted special needs population (i.e., dual-eligible, institutionalized, or chronic condition) at the plan level? |
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Provide a description and examples of the types of data collected, analyzed, and reported that measure health outcomes and indices of quality pertaining to the SNP targeted special needs population (i.e., dual-eligible, institutionalized, or chronic condition) at the plan level. |
XX |
XX |
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Applicant collects, analyzes, and reports data that measure access to care as evidenced by measures from the care coordination domain (e.g., service and benefit utilization rates, or timeliness of referrals or treatment). |
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Provide a description and examples of data collected, analyzed, and reported that measure access to care. |
XX |
XX |
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Applicant collects, analyzes, and reports data that measure improvement in beneficiary health status as evidenced by measures from functional, psychosocial, or clinical domains (e.g., quality of life indicators, depression scales, or chronic disease outcomes). |
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Provide a description and examples of data collected, analyzed, and reported that measure improvement in beneficiary health status. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure staff implementation of the SNP model of care as evidenced by measures of care structure and process from the continuity of care domain (e.g., National Committee for Quality Assurance accreditation measures or medication reconciliation associated with care setting transitions indicators). |
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Provide a description and examples of data collected, analyzed, and reported that measure staff implementation of the SNP model of care. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure comprehensive health risk assessment as evidenced by measures from the care coordination domain (e.g., accuracy of acuity stratification, safety indicators, or timeliness of initial assessments or annual reassessments). |
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Provide a description and examples of data collected, analyzed, and reported that measure comprehensive health risk assessment. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure implementation of an individualized plan of care as evidenced by measures from functional, psychosocial, or clinical domains (e.g., rate of participation by IDT members and beneficiaries in care planning). |
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Provide a description and examples of data collected, analyzed, and reported that measure implementation of an individualized plan of care. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure use of a provider network having targeted clinical expertise as evidenced by measures from medication management, disease management, or behavioral health domains. |
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Provide a description and examples of data collected, analyzed, and reported that measure use of a provider network having targeted clinical expertise. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure delivery of services across the continuum of care. |
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XX |
Provide a description and examples of data collected, analyzed, and reported that measure delivery of services across the continuum of care. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure delivery of add-on services and benefits that meet the specialized needs of the most vulnerable beneficiaries as evidenced by measures from the psychosocial, functional, and end-of-life domains. |
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XX |
Provide a description and examples of data collected, analyzed, and reported that measure delivery of extra services and benefits that meet the specialized needs of the most vulnerable beneficiaries. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure use of evidence-based practices and/or nationally recognized clinical protocols. |
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XX |
Provide a description and examples of data collected, analyzed, and reported that measure use of evidence-based practices and/or nationally recognized clinical protocols. |
XX |
XX |
XX |
Applicant collects, analyzes, and reports data that measure the use of integrated systems of communication as evidenced by measures from the care coordination domain (e.g., call center utilization rates, rates of beneficiary involvement in care plan development, etc.). |
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XX |
Provide a description and examples of data collected, analyzed, and reported that measure the use of integrated systems of communication. |
XX |
XX |
XX |
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. |
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XX |
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Uploads Requested in the 2010 SNP Proposal Included in the MA Application
New and Expansion of Existing Dual-eligible SNPs Proposal Applications
1) SNP Service Area
Service area (State and County codes)
Names of States
2) State Medicaid Agency Contracts
Copy of signed State Medicaid Agency(ies) contract
State Medicaid Agency(ies) contract approved service area
3) State Medicaid Agency Contract Enrolled Population
Description of the Medicaid subset for other than what is listed as Y/N response
Description of the Medicaid benefits covered in the State Medicaid contract
Description of the cost-sharing protections covered in the State Medicaid contract
Description of the identification and sharing information on Medicaid provider participation covered in the State Medicaid contract
Description of the MAO’s responsibilities, including financial obligations, to provide or arrange for Medicaid benefits covered in the State Medicaid contract
Name of the contact individual at the State Medicaid Agency(ies)
Address of the State Medicaid agency(ies) contact person
Phone number of the State Medicaid agency(ies) contact person
E-mail address of the State Medicaid agency(ies) contact person
Description of the process to verify Medicaid eligibility of individuals through the State
Description of the process to coordinate Medicare and Medicaid services for dual-eligible individuals
New and Expansion of Existing Severe or Disabling Chronic Condition SNPs Proposal Applications
1) SNP Service Area
Service area (State and County codes)
Names of States
New and Expansion of Existing Institutional SNPs Proposal Applications
1) SNP Service Area
Service area (State and County codes)
Names of States
2) SNPs Enrolling Individuals Residing in Institutions
List of contracted long-term care facilities
List of assisted-living facilities (if applicant/SNP is contracting with ALFs)
Copy of the State Level of Care assessment tool
URL to access the State Level of Care assessment tool (if web-based)
Name of the entity performing the LOC assessment
Address of the entity
ERSD Waiver Requests
Description of how the SNP intends to serve the unique needs of the ESRD beneficiaries
List of the contracted dialysis facility(ies)
List of the contract transplant facility(ies)
Description of any additional service(s) provided to members with ESRD
Description of the interdisciplinary care team coordinator role in the assessment and delivery of services needed by beneficiaries with ESRD
Model of Care
1) Health Risk Assessment
Copy of the comprehensive health risk assessment tool
Note: Does not include items which require a text box to input information (e.g., a date)
PART 5 INSTRUCTIONS FOR COMPLETING CMS FORMS
2.1. Form and Table Management
Application forms and tables associated with the applications are available in separate Microsoft Word or Excel files that are available at http://www.cms.hhs.gov/MedicareAdvantageApps/. Microsoft Word files located on the CMS web site are posted in a .zip format.
Most tables require that a separate table be submitted for each area/region/county that an applicant is requesting, by Medicare geographic area. If copies of a table are needed, create multiple blank tables within the same file, being sure to place a hard page break between each table. Save the entire file, now containing two or more tables, with the original file name.
Please note that all documents submitted to HPMS with the application must include file names as specified in Part 6.
2.2 Instructions for CMS Insurance Coverage Table
Instructions
Complete the table by inserting the amount of insurance coverage or other arrangements the applicant has for major types of loss and liability.
Provide in HPMS, a completed copy of this table in PDF format.
Column Explanations:
Type - Identifies the various types of insurance.
Carrier - Enter the name of the insurance carrier for each insurance type identified by the Applicant.
Entity covered - Enter the name of the entity (organization) that is covered by this insurance.
Description: Deductibles, Co-insurance, Minimum & Maximum Benefits
Premiums - Enter the amount of the premiums.
Period Policies are in effect - Enter the periods that the policies are in effect.
Other Arrangements to Cover These Risks - Enter any other insurance arrangements to cover the Applicant’s risks.
2.3. Instructions for CMS State Certification Form
The applicant should complete items 1 – 3 and then forward the form to the appropriate State Agency Official for completion of items 4 – 7. Upon completion of items 4 – 7, the State agency Official will return the form to the applicant. The applicant must provide in HPMS a copy of this executed form using a PDF format.
All questions must be fully answered. Sufficient space has been provided, however, if additional space is required; please add pages to provide a more detailed response. Additional information can be provided if the Applicant feels it will further clarify the response.
The State Certification form demonstrates that the contract being sought by the applicant with CMS is within the scope of the license granted by the appropriate State regulatory agency and is authorized to bear financial risk.
Items 1 - 3 (to be completed by the Applicant):
1. List the name and complete address of the organization that will enter into the MA contract with CMS.
2. The Applicant should list the type of license (if any) currently being held in the State where an MA contract is being sought.
3. Applicants must specify the type of MA contract being requested from CMS. CMS wants to verify that any MA plans being offered by the MA organization in the State meet State licensure and solvency requirements applicable to a Federal health plan.
Note: Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the Social Security Act and significantly broadened the scope of Federal preemption of State law. The revised MA regulations at Sec. 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.
Items 4 - 7 (to be completed by State Official):
4. List the reviewer’s pertinent information in case CMS needs to communicate with the individual conducting the review at the State level.
5. Some States require several departments/agencies to review licensure requests. CMS wants to know about other departments/agencies involved in such review/approval.
6. Check the appropriate box to indicate whether the applicant meets State financial solvency requirements.
7. Indicate State Agency or Division, including contact name and complete address, which is responsible for assessing whether the applicant meets State financial solvency requirements.
State Certification Section: Enter the following information:
Name of the Applicant (organization)
State in which the Applicant is licensed
Name of the certifying State Agency
Signature of State Official
Title of State Official
Date of State Certification
2.4. Instructions for CMS Provider Arrangements by County Table
Instructions:
Provide in HPMS, a separate table for each county, partial county, or delivery system.
Column Explanations:
Category - Staff/Group/ IPA/PHO/Direct:
Member Physicians - Licensed Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (D.O.) who are members and/or employees of the entity that contracts with the MA organization.
Member Non-Physicians - Midwives, nurse practitioners, or chiropractors, etc., who are members and/or employees of the entity that contracts with the MA organization.
Non-Member Physicians - Licensed M.D. and D.O. who are contracted and/or subcontracted to provide services on behalf of the entity but are not members and/or employees of the entity.
Non-Member, Non-Physician - Mid-wives, nurse practitioners, or chiropractors, etc., who are subcontracted to provide services to the entity but are not members and/or employees of the entity.
Direct Contract HMO-Physicians - Licensed M.D. and D.O. who have entered into a direct contract with the HMO.
Type of Contract and/or Agreement – Insert number of contracts, or Letter of Agreements (LOA).
Note: Letters of intent, Memorandums of Understanding and Memorandums of Agreement are not acceptable. CMS will accept any legally binding written arrangement.
Number of Contracts and/or Agreements - List the total number of signed contracts and/or agreements.
Automatic Renewal of Contracts and/or Agreements – Insert number of contracts/and or Agreements that are automatically renewed.
Date Executed - Enter the date or date range (in which all contracts and/or agreements were finalized for the particular category.
Contract and/or Agreement Template name - List the template name (i.e., Template A or Templates A- C) for each category.
2.5. Instructions for CMS Provider Participation Contracts and/or Agreements Matrix
This matrix should be completed by MA applicants and should be use to reflect the applicants first tier, downstream and related entity contracts and/or agreements.
Instructions:
Provide in HPMS using a PDF format, a separate matrix for each county or partial county.
Enter name of the provider(s)/group(s) or entity that the MA organization contracts with to provide services to Medicare enrollees. Each matrix will need to be filled out for all first tier, downstream and related entity providers.
Designate if provider is first tier contracted provider with a "(1)" next to the name of that provider(s)/group(s) or other entity.
Designate downstream contracted provider(s), group, or other entity with a "(DS)".
Under each column, list the page number where the provision that meets the regulatory requirement can be found in each of the contracts and/or agreements templates for that particular provider(s), group(s) and other contracted entities.
Note: This matrix contains a brief description of MA regulatory requirements; please refer to full regulatory citations for an appropriate response.
2.6. Instructions for CMS Administrative/Management Delegated Contracting or Arrangement Matrix
This matrix should be completed by network model MA applicants and should be use to reflect the applicants first tier and downstream contracts and/or agreements.
Instructions:
Enter name of entity or entities that the MA applicant has contracted with to provide administrative services to Medicare enrollees
Note: MSA applicants will enter the name of the entity that the applicant has arranged to offer MA MSA accounts in accordance with §1853(e)(2) of the Act.
Matrix will need to be completed for the entire administrative first tier and downstream contracted entities that will be providing administrative services to the MA applicants.
Designate if the contracted entity is a first tier administrative provider with a "(1) next to the name of the provider(s), group or other entity.
Designate any downstream contracted entities for administrative services with "(DS)" next to the name of the entity.
Under each column, list the page number where the regulation can be found in each of the administrative services contracts and/or agreements for that particular contracted entity.
Note: Matrix contains a brief description of MA regulatory requirements; please refer to full regulatory citations for an appropriate response.
2.7. General Instructions for CMS HSD Tables 1, 2, 2a, 3, 3a, 4, 5
(Not required for non-network Private Fee For Service PFFS,)
These tables should be completed by contracted-network MA applicants, excluding RPPO applicants.
Instructions:
If an MA applicant has a network exclusive to a particular plan, the applicant must provide in HPMS four separate HSD tables for each plan.
The applicant must list the plan or plans name to which a table applies at the top of each tables. If the table applies to all plans, state “All”.
Enter the date that the tables were constructed next to “date prepared”. The tables should reflect the applicants fully executed contracted network providers and facilities that are in place on the date of submission.
Note: For CMS purposes, contracts are considered fully executed when both parties have signed.
If a type of provider or facility is not available in a county but the pattern of care is to obtain those medical services from another county listed on an HSD table, the applicant must
Provide in HPMS a narrative of this exception/these exceptions in a PDF file and list the providers in the HSD tables. This narrative should be separated by county and then by HSD table, within each county.
In the rarity that non-contracted providers must be used to provide services to members, applicant must explain within the PDF file how the applicant will ensure that members are not balance-billed for these services and that the non-contracted providers are reimbursed sufficiently to provide health care services.
Applicant must provide these tables in HPMS as Excel documents.
HSD Table format must include:
Set print area and page set-up to ensure all columns fit within one 81\2 sheet of paper either portrait or landscape for some HSD tables, the number of rows may require additional pages.
Set repeat rows to specify the title of the worksheet and the column headings for HSD tables that require multiple pages to be printed. For example, the CMS reviewer must be able to view subsequent pages of the HSD table with the same column headings as the first page.
Save format settings prior to uploading into HPMS.
NOTE: RPPO applicants are required to complete HSD tables but should follow instructions in Section 2 of this application.
2.7.1 Table: HSD-1: County/Delivery System Summary of Providers by Specialty
Instructions:
Physicians and specialists should be counted only once per county on this table even if the provider has more than one location in a county. Facilities such as hospitals and clinics that provide more than one service listed on HSD-3, should be counted once on HSD-1 for each service provided by the facility.
If the applicant uses a subnetwork or has multiple delivery systems within the county/service area, the applicant must complete a separate HSD-1 table for each delivery system. Each HSD-1 table should be representative of the aggregate numbers of providers for the delivery system being described.
Initial applicants must include a numeric entry for each provider type. If the number of providers is zero, please enter a zero. Every county in your proposed service area must include an entry for every provider type
SAE applicants must include a numeric entry for each provider type for the counties in which expansion is to occur.
If there are other specialties that are not listed, applicant should add lines under "Pancreas Transplant Facilities" to cover these specialists. Please do not change provider specialty order as listed on HSD-1.
Applicants will need to provide the SSA State/County Code for every provider type.
Applicant must indicate the total number of providers in EVERY SSA State/county code in their pending service area
Applicant must insert the project enrollment numbers for the county.
Column Explanations:
Specialty - Self-explanatory-
Note: For radiology, chiropractic, and podiatry list only those providers who are contracted directly with the MAO or downstream entity.
Available Medicare Participating Providers in County - List the number of Medicare participating providers located in the county. Information can be obtained from the Medicare Carriers.
Medicare Provider Breakdown - List the number of contracted providers by type of contract (direct arrangement or downstream arrangement).
Total # of Providers - Add up the total number of providers per specialty listed in columns 5 & 6.
May Providers Serve as PCPs? - Enter "Y" if providers may serve as a member's Primary Care Physician. Enter "N" if providers may not serve as a member's Primary Care Physician.
Total # of PCPs Accepting New Patients - If "Y" was entered in column 8, list the total number of providers who are accepting new Medicare patients. New patients are defined as patients who were not previously seen by the physician. If "N" was entered in column 8, please leave the cell blank.
Total # of PCPs Accepting Only Established Patients - If "Y" was entered in column 9, list the total number of providers who are accepting only established patients. Established patients are defined as patients who are already patients of the physician's practice, either under original Medicare, another Medicare managed care organization, or through an age-in arrangement. If "N" was entered in column 8, please leave cell blank.
Other Counties Served - Other counties that provider will serve.
2.7.2 Table: HSD-2: Provider List - List of Physicians and Other Practitioners by County
Instructions:
Applicant must arrange providers alphabetically by county, then alphabetically by specialty, and finally numerically by zip code.
If a provider sees patients at more than one location, list each location separately.
All providers that compose the total counts on HSD-1 must be listed on HSD-2
Column Explanations:
Name of Physician—Self-Explanatory. Please include chiropractors, podiatrists, Mid-Level Practitioner nurse practitioners, and physician assistants.
Specialty - Self-explanatory.
Contract Type - Indicate type of contract with provider. D=Direct and W=Downstream.
Step 4-8
Service Address - Specify the address (street, city, state, and zip code, county) where the provider serves patients. If a provider sees patients at more than one location, list each location separately.
Provider Previously Listed? - Enter "Y" if the same provider is previously listed in the rows above. Enter "N" if a provider is not previously listed in the rows above (e.g., the first time a provider listed on the worksheet, an "N" should be entered.)
Contracted Hospital Where Privileged - Identify one contracted hospital in the service area where the provider has admitting privileges, other than courtesy privileges. If the provider does not have admitting privileges, please leave cell blank. If the provider does not have admitting privileges, other than one contracted hospital, please use an abbreviation and place a footnote on the bottom of each page.
Will Provider Serve as PCP? - Enter "Y" if provider will serve as a member's Primary Care Physician. Enter "N" if provider will not serve as a member's Primary Care Physician.
If PCP, Accepts New Patients? - If "Y" was entered in column 11, indicate if provider accepts new patients by entering a "Y" or "N" response. If "N" was entered in column 11, please leave cell blank.
If PCP, Accepts Only Established Patients? - If "Y" was entered in column 11, indicate if provider accepts only established patients by entering a "Y" or "N" response. If "N" was entered in column 11, please leave cell blank.
Does MCO Delegate Credentialing? - Enter "Y" if the applicant delegates the credentialing of the physician. Enter "N" if the applicant does not delegate credentialing of the physician. If credentialing is not required, please leave cell blank.
If Credentialing is Delegated, List Entity- If credentialing is not performed by the applicant, enter the name of the entity that does the credentialing. The name entered should match one of the entities listed on the "Entity Listing in Preparation for Monitoring Review" document that was previously provided to the RO.
Medical Group Affiliation - For each provider reflected on the table indicate the name of the medical group/IPA affiliation for that provider. This data is necessary so that CMS may sort the table to assess provider network adequacy without requiring that a separate HSD 2 table be completed for each medical group/IPA that comprises a distinct health service delivery network. Note: Leave this column blank if the provider is not affiliated with a medical group/IPA. For example if you have a provider with a direct contract that is affiliated with a “XYZ” medical group/IPA you must input “DC” in column number 3 and the name of “XYZ” medical group/IPA in column 16. If your provider has a direct contract but is not affiliated with a medical group/IPA then you must input “DC” in column 3 and leave column 16 blank.
Employment Status - Indicate whether the provider is an employee of a medical group/IPA or whether a downstream contract is in place. Insert “E” if the provider is an employee. Insert “DC” if a downstream contract is in place for the provider.
2.7.3 Table HSD-2a: PCP/Specialist Contract Signature Page Index
The purpose of this index is to map contracted PCPs and specialty physicians listed in HSD2 to the tab indicating the template contract used to make official the relationship between the applicant and the provider. For SAE MA applicants, the grid will also document whether any of the applicant’s current providers will be part of the network available in the expansion area. If so, the provider should be reflected in the index to 1) establish the provider as a part of the contracted network for the expansion area, and 2) to provide the template contract used to formalize the arrangements. However, since these providers are already established as providers for the applicants, signature pages will not be requested to support the existence of written arrangements. It is assumed that these arrangements were in place prior to the filing of the service area expansion.
Column Explanations:
PCP/Specialist - Enter the contract name as indicated in HSD2 for all PCPs and specialist contracts.
Contract Template/Tabs - Documentation to support the types of contracts executed should be submitted as part of this application. Enter the tab title/section to where the documentation supporting the arrangements between the physician and the applicant can be found. Then indicate the specific contract used for each physician reflected in the PCP/Specialist column.
Existing Network – Indicate whether the provider was previously established as a network provider in the applicants existing service area. (Not applicable for new MA applicants)
2.7.4 Table HSD-3: Arrangements for Medicare Required Services by County
Instructions:
Applicant must arrange contracted entities alphabetically by county and then alphabetically by type of provider. All direct and downstream providers of services should be listed.
Only list the providers who provide the Medicare required services that are listed in columns 9-28. Please do not list any additional providers or services.
If any providers listed on HSD-2 provide the services reviewed on HSD-3, list them as follows:
If all of the providers listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2" in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by all of the providers listed on HSD-2.
If all providers of a certain specialty listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2 with specialty (enter specialty) " in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by the providers of a certain specialty as listed on HSD-2.
If all providers who may serve as a "PCP" as listed on HSD-2 provide one or more of the services listed in columns 9-28, enter "all providers listed on HSD-2 who may serve as a PCP " in the "Name of Provider" column; enter "Other" for the "Type of Provider" column; leave columns 3-8 blank; and place an "X" in column(s) that represent the services provided by the providers that may serve as PCPs as listed on HSD-2.
Column Explanations:
Name of Provider - Enter name of contracted provider.
Type of Provider - Enter type of contracted provider.
ASC = Ambulatory Surgical Center
OPT = Outpatient physical therapy, occupational therapy, or speech pathology facility
CMHC = Community Mental Health Center
PH = Psychiatric Hospital
CORF = Comprehensive Outpatient Rehabilitation Facility
RAD = Radiology Therapeutic & Diagnostic
ESRD = Outpatient Dialysis Center
RH = Rehabilitation Hospital
FQHC = Federally Qualified Health Center
RHC = Rural Health Clinic
HHA = Home Health Agency
RNHC - Religious Nonmedical Health Care Institutions
HOSP = Acute Care Hospital
SNF = Skilled Nursing Facility
Lab = Laboratory
OTHER = any provider not listed above, such as durable medical equipment suppliers, transplant facilities, etc.
LH = Long Term Hospital
Steps 3-6
Location - Enter street address/city/state/zip code.
County Served by Provider - List one county the provider serves from this location. (If more than one county is served, repeat information as entered in columns 1-6 and columns 9-28, changing column 7 as applicable.)
Provider Previously Listed? - Enter "Y" if the same provider is previously listed in the rows above. Enter "N" if a provider is not previously listed in the rows above (e.g., the first time a provider listed on the worksheet.)
Steps 9-28
Services - Mark an "X" in the box if the provider/facility provides this service
2.7.5 Table HSD-3a: Ancillary/Hospital Contract Signature Page Index
The purpose of this index is to map contracted ancillary or hospital providers listed in HSD3 to the tab indicating the template contract used to make official the relationship between the applicant and the provider. The grid will also document whether any of the applicant’s current providers will be part of the network available in the expansion area. If so, the provider should be reflected in the index to 1) establish the provider as a part of the contracted network for the expansion county, and 2) to provide the template contract used to formalize the arrangements. However, since these providers are already established as providers for the applicant, signature pages will not be requested to further support the existence of written arrangements. It is assumed that these arrangements were in place prior to the filing of the service area expansion.
Column Explanations:
Ancillary/Hospital HSD3– Enter the contract name as indicated in HSD3 for all ancillary and hospital contracts.
Tab Name – Indicate the Tab Name containing the template contract executed between the provider and the applicant.
Existing Network – Indicate whether the provider was previously established as a network provider in the applicant’s existing service area. (Not applicable for new MA applicants)
2.7.6 Table HSD-4: Arrangements for Additional and Supplemental Benefits
Instructions:
If there are other services that are not listed, add columns to the right of the "Screening-Vision" column to cover these services.
Only list the providers who provide the additional and supplemental benefit services as listed in the "services" columns (columns 7-12). Note: if other services are added to the right of the "Screening-Vision" column (column 12), those providers should also be listed.
If any providers listed on HSD-2 provide the services reviewed on HSD-4, list them as follows:
If all of the providers listed on HSD-2 provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2" in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by all of the providers listed on HSD-2.
If all providers of a certain specialty listed on HSD-2 provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2 with specialty (enter specialty) " in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by the providers of a certain specialty as listed on HSD-2.
If all providers listed on HSD-2 will serve as "PCPs" and provide one or more of the services listed in columns 7-12, enter "all providers listed on HSD-2 who may serve as a PCP " in the "Name of Provider" column; leave columns 2-6 blank; and place an "X" in column(s) that represent the services provided by the providers that may serve as PCPs as listed on HSD-2.
Please list all direct and downstream providers of services.
Arrange benefits alphabetically by county and then numerically by zip code.
Column Explanations:
Name of Provider - Enter name of the contracted provider, for example – Comfort Dental Group(Dental); Comfort Eyewear Associates (Eyeglasses/Contacts); Comfort Hearing Aids Associates (Hearing Aids); XYZ Pharmacy (Prescription Drugs – outpatient); Comfort Hearing, Inc. (Screening-Hearing); Comfort Vision Specialists (Screening – Vision).
Steps 2-5
Location - Enter street address/city/state/zip code, for example – 123 Main Street, Baltimore, MD 11111
County Served by Provider - List one county the provider serves from this location. (If more than one county is served, repeat information as entered in columns 1-5 and columns 7-12, changing column 6 as applicable.) Examples: Canyon County, Peaks County.
Steps 7-12-
Services - Mark an "X" in the box if the provider provides this service. For the providers that are listed in Column 1, please indicate which services this provider provides.
2.7.7 Table HSD-5: Signature Authority Grid
The purpose of this grid is to evidence whether physicians of a provider group are employees of the medical practice. The grid will display the medical group, the person authorized to sign contracts on behalf of the group and the roster of employed physicians of that group.
Column Explanations:
Practice Name – The name of the provider group for which a single signature authority exists on behalf of the group.
Signature Authority – The representative of the medical practice with authority to execute arrangements on behalf of the group
Physicians – Reflect all of the physicians in HSD2 for which the signature authority is applicable
2.8. Table: Essential Hospital Designation Table
Please complete this form with the indicated information about each hospital that applicant seeks to have designated as essential. Please note that, under Section 1858(h) of the Social Security Act (the Act) and 42 CFR 422.112(c)(3), applicant organization must have made a good faith effort to contract with each hospital that it seeks to have designated as essential. A “good faith” effort is defined as having offered the hospital a contract providing for payment rates in amounts no less than the amount the hospital would have received had payment been made under section 1886(d) of the Act. The attestation on the following page must be completed and submitted with the completed chart.
PART 6 LISTS OF REQUESTED DOCUMENTS
The following is a summary of the documentation that must be submitted with the Medicare Advantage application. To assist in the application review Applicant’s must submit these documents using the file name provided in the table. Applicants are encouraged to use the file name format that is provided below. If the Applicant is required to provide multiple versions of the same document, the Applicant should insert a number, letter, or even the state behind the file name for easy identification.
Part 2 Initial Applications--Section 1-- All MA Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
1.1 Experience & Organization History
|
Yes |
PDF. File |
HXXX_History-1. pdf |
|
1.2 Administrative Management |
Yes |
PDF. File |
HXXX_Insurance-1.pdf |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_StateLicense-StateAbbreviation.pdf |
|
1.3 State Licensure
|
Yes |
PDF. File |
Hxxxx_StateCert-StateAbbreviation.pdf |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
1.3 State Licensure
|
No |
PDF. File |
Hxxxx_StateDBA-StateAbbreviation.pdf |
|
1.4 Business Integrity
|
No |
PDF. File |
Hxxxx_IntegrityDis.pdf |
|
1.6 Key Management Staff
|
No |
PDF. File |
Hxxxx_KeyManagement.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_AuditedStatements.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_ANAICFinancialPlan.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_QuarterlyHealthBlanK.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_FinancialPlan.pdf |
|
1.7 Fiscal Soundness |
No |
PDF. File |
Hxxxx_FinancialDisclosure.pdf |
|
1.8 Service Area
|
No |
PDF. File |
Hxxxx_PartialCountyJust.pdf |
|
1.8 Service Area
|
No |
PDF. File |
Hxxxx_County
Name-GeoScrptMaps.pdf |
|
1.9 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderTable.pdf |
|
1.9 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_PContract-Template
1-PCP.pdf, Hxxxx_PContract-Template 2-IPA.pdf |
|
1.9 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_
DownstreamContract-Template
1-MG.pdf.
Hxxxx_DownstreamContract-Template 1-IPA.pdf |
|
1.9 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderMatrix
–Template 1-MG.pdf. |
|
1.10 Contracts for Administrative & Management Services |
No |
PDF. File |
Hxxxx_AdminContract (number, version, or template).pdf
|
|
1.10 Contracts for Administrative & Management Services |
Yes |
PDF. File |
Hxxxx_AdminDelContractMatrix (number, version, or template).PDF |
|
1.11 Health Services Delivery (HSD)
|
Yes |
Excel File |
Hxxxx_HSD1..xls
Hxxxx_HSD2..xls |
|
1.18 |
Yes |
PDF. File |
Hxxxx_DUA.pdf |
Part 2 Initial Applications--Section 2 –RPPO Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateLicense-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_StateCert-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateDBA-StateAbbreviation.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccesStandards (Urban or Rural).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccessStandardsChart (State Abbreviation).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_ContingenyPlanAccess.pdf |
|
2.3 Essential Hospital
|
Yes |
Excel File |
Rxxxx_EssentialTable.xls |
|
2.3 Essential Hospital
|
Yes |
PDF. File |
Rxxxx_EssenstialAttest(Hospital Name).pdf |
Part 2 Initial Applications--Section 3-PFFS Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
3.1 Access to Services |
Yes |
Excel File. |
Hxxxx_HSD1.xls
Hxxxx_HSD2..xls |
|
3.1 Access to Services |
No |
PDF. File |
Hxxxx_NationalCoverageScipt.pdf |
|
3.1 Access to Services |
No |
PDF. File |
Hxxxx_DiversityScrpt.pdf |
|
3.3 Payment Provisions
|
Model Guidance |
PDF. File |
Hxxxx_ReimbursementGrid.pdf |
Part 2 Initial Applications--Section 4- MSA/ MSA Demo
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
4.2 Access to Services
|
Yes |
Excel File |
Hxxxx_HSD1..xls
Hxxxx_HSD2..xls |
|
4.4 Payment Provisions
|
Model Guidance |
PDF. File |
Hxxxx_ReimbursementGrid.pdf |
Part 2 Initial Applications--Section 5- MSA DEMO ONLY
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_CostsharingScript.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_PreventServices.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_ProjectedEnrolllment.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_NonMedicareSrvcs.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_DepositsScript.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_EnrollmentTracking.pdf |
|
5.1 MSA Demonstration Addendum
|
No |
PDF. File |
Hxxxx_RecoverDeposits.pdf |
Part 3 Service Area Expansions--Section 1--All MA Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_StateLicense-StateAbbreviation.pdf |
|
1.2 State Licensure
|
Yes |
PDF. File |
Hxxxx_StateCert-StateAbbreviation.pdf |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
1.2 State Licensure
|
No |
PDF. File |
Hxxxx_StateDBA-StateAbbreviation.pdf |
|
1.3 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderTable.pdf |
|
1.3 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_PContract-Template
1-PCP.pdf, Hxxxx_PContract-Template 2-IPA.pdf |
|
1.3 Provider Contracts & Agreements
|
No |
PDF. File |
Hxxxx_
DownstreamContract-Template
1-MG.pdf.
Hxxxx_DownstreamContract-Template 1-IPA.pdf |
|
1.3 Provider Contracts & Agreements
|
Yes |
PDF. File |
Hxxxx_ProviderMatrix –Template 1-MG.pdf. |
|
1.4 Contracts for Administrative & Management Services |
No |
PDF. File |
Hxxxx_AdminContract (number, version, or template).pdf
|
|
1.4 Contracts for Administrative & Management Services |
Yes |
PDF. File |
Hxxxx_AdminDelContractMatrix (number, version, or template).PDF |
|
1.5 Health Services Delivery (HSD)
|
Yes |
Excel File |
Hxxxx_HSD1.County Name.xls
Hxxxx_HSD2.County Name.xls |
|
1.6 Service Area
|
No |
PDF. File |
Hxxxx_PartialCountyJust.pdf |
|
1.6 Service Area
|
No |
PDF. File |
Hxxxx_County
Name-GeoScrptMaps.pdf |
Part 3 Service Area Expansion--Section 2 --RPPO Applicants
Document Requested |
Reference within Application |
Template Provided |
Format |
File Name |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateLicenseNJ.pdf
|
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_StateCertNY.pdf |
|
2.1 State licensure RPPO
|
No |
PDF. File |
Rxxxx_StateDBA-NJ.pdf |
|
2.1 State licensure RPPO
|
Yes |
PDF. File |
Rxxxx_UnderStateReview-StateAbbreviation.pdf. |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccesStandards (Urban or Rural).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_AccessStandardsChart (State Abbreviation).pdf |
|
2.2 Access Standards
|
No |
PDF. File |
Rxxxx_ContingenyPlanAccess.pdf |
|
2.3 Essential Hospital
|
Yes |
Excel File |
Rxxxx_EssentialTable.xls |
|
2.3 Essential Hospital
|
Yes |
PDF. File |
Rxxxx_EssenstialAttest(Hospital Name).pdf |
List available at http://www.cms.hhs.gov/HealthPlansGenInfo/Downloads/cmsregional.pdf
RO I CMS – BOSTON REGIONAL OFFICE
JOHN F. KENNEDY FEDERAL BUILDING, ROOM 2375, BOSTON, MA 02203
TELEPHONE: 617-565-1267
STATES: CONNECTICUT, MAINE, MASSACHUSETTS, NEW HAMPSHIRE, RHODE ISLAND, AND VERMONT
RO II CMS – NEW YORK REGIONAL OFFICE
26 FEDERAL PLAZA, ROOM 3811, NEW YORK, NY 10278
TELEPHONE: 212-616-2358
STATES: NEW JERSEY, NEW YORK, PUERTO RICO, and VIRGIN ISLANDS
RO III CMS – PHILADELPHIA REGIONAL OFFICE
PUBLIC LEDGER BUILDING, SUITE 216, 150 S. INDEPENDENCE MALL WEST, PHILADELPHIA PA 19106-3499
TELEPHONE: 215-861-4224
STATES: DELAWARE, DISTRICT OF COLUMBIA, MARYLAND, PENNSYLVANIA, VIRGINIA, WEST VIRGINIA
RO IV CMS – ATLANTA REGIONAL OFFICE
ATLANTA FEDERAL CENTER, 61 FORSYTH ST., SW, SUITE 4T20, ATLANTA, GA 30303-8909
TELEPHONE: 404-562-7362
STATES: ALABAMA, FLORIDA, GEORGIA, KENTUCKY, MISSISSIPPI, NORTH CAROLINA, SOUTH CAROLINA, AND TENNESSEE
RO V CMS – CHICAGO REGIONAL OFFICE
233 NORTH MICHIGAN AVENUE, SUITE 600, CHICAGO, IL 60601-5519
TELEPHONE: 312-353-3620
STATES: ILLINOIS, INDIANA, MICHIGAN, MINNESOTA, OHIO, AND WISCONSIN
RO VI CMS – DALLAS REGIONAL OFFICE
1301 YOUNG STREET, Room 833, DALLAS, TX 75202
TELEPHONE: 214-767-4471
STATES: ARKANSAS, LOUISIANA, OKLAHOMA, NEW MEXICO, AND TEXAS
RO VII CMS – KANSAS CITY REGIONAL OFFICE
RICHARD BOLLING FEDERAL OFFICE BUILDING, 601 EAST 12th ST., ROOM 235, KANSAS CITY, MO, 64106
TELEPHONE: 816-426-5783
STATES: IOWA, KANSAS, MISSOURI, AND NEBRASKA
RO VIII CMS -- DENVER REGIONAL OFFICE
1600 BROADWAY, SUITE 700, DENVER, CO 80202
TELEPHONE: 303-844-2111
STATES: COLORADO, MONTANA, NORTH DAKOTA, SOUTH DAKOTA, UTAH, AND WYOMING
RO IX CMS – SAN FRANCISCO REGIONAL OFFICE
DIVISION OF MEDICARE HEALTH PLANS
90 7th Street Suite 5-300 (5W), SAN FRANCISCO, CA 94103-6707
TELEPHONE: 415-744-3617
STATES: ARIZONA, CALIFORNIA, GUAM, HAWAII, NEVADA, AND AMERICAN SAMOA, AND THE COMMONWEALTH OF NORTHERN MARIANA ISLAND
RO X CMS -- SEATTLE REGIONAL OFFICE
MEDICARE MANAGED CARE BRANCH
2201 6th AVENUE, RX-47, ROOM 739, SEATTLE, WA 98121-2500
TELEPHONE: 206-615-2351
STATES: ALASKA, IDAHO, OREGON, AND WASHINGTON
Draft Redlined MAAPP-12-4-2008
(ver.1)
| File Type | application/msword |
| File Title | PART I- FOR APPLICANTS THAT ARE SUBMITTING INITIAL APPLICANTIONS |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2008-12-05 |
| File Created | 2008-12-05 |