CMS-10237 Part C - Medicare Advantage and 1876 Cost Plan Expansion

PART C -MEDICARE ADVANTAGE

and 1876 COST PLAN EXPANSION APPLICATION

For all new applicants and existing Medicare Advantage contractors seeking to expand a service area -- CCP, PFFS, MSA, RPPO, SNPs, and EGWPs

For all existing Medicare Cost Plan contractors seeking to expand the contract service area

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMS)

Center for Medicare (CM)

Medicare Drug and Health Plan Contract Administration Group (MCAG)

Medicare Advantage Coordinated Care Plan (CCPs) must offer at least one Medicare Advantage plan that includes a Part D prescription drug benefit (MA-PD) in each county of its service area. Therefore, CCP applicants 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 47 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.

1 GENERAL INFORMATION 8

1.1 Overview 8

1.2 Types of MA Products 8

1.3 Important References 9

1.4 Technical Support 9

1.5 The Health Plan Management System (HPMS) 11

1.6 Submitting Notice of Intent to Apply (NOIA) 12

1.7 Additional Information 13

1.8 Due Dates for Applications – Medicare Advantage and Medicare Cost Plans 15

1.9 Request to Modify a Pending Application 17

1.10 Application Determination and Appeal Rights 18

2 INSTRUCTIONS 18

2.1 Overview 18

2.2 Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) 19

2.3 Applicants Seeking to Offer Employer/Union Direct Contract MAO 19

2.4 Applicants Seeking to Offer Special Needs Plans (SNPs) 19

2.5 Applicants Seeking to Offer Medicare Cost Plans 20

2.6 Applicants Seeking to Serve Partial Counties 20

2.7 Types of Applications 20

2.8 Chart of Required Attestations by Type of Applicant 21

2.9 Health Services Delivery (HSD) Tables Instructions 23

2.10 Document (Upload) Submission Instructions 24

2.11 MA Part D (MA-PD) Prescription Drug Benefit Instructions 24

3 ATTESTATIONS 25

3.1 Experience & Organization History 25

3.2 Administrative Management 27

3.3 State Licensure 29

3.4 Program Integrity 32

3.5 Compliance Plan 32

3.6 Key Management Staff 33

3.7 Fiscal Soundness 33

3.8 Service Area 34

3.9 CMS Provider Participation Contracts & Agreements 34

3.10 Contracts for Administrative & Management Services 36

3.11 Health Services Management & Delivery 38

3.12 Quality Improvement Program 40

3.13 Marketing 41

3.14 Eligibility, Enrollment, and Disenrollment 44

3.15 Working Aged Membership 47

3.16 Claims 48

3.17 Communications between MAO and CMS 49

3.18 Grievances 50

3.19 Appeals 51

3.20 Health Insurance Portability and Accountability Act of 1996 (HIPAA) 54

3.21 Continuation Area 55

3.22 Part C Application Certification 55

3.23 RPPO Essential Hospital 56

3.24 Access to Services (PFFS & MSA) 56

3.25 Claims Processing (PFFS & MSA) 59

3.26 Payment Provisions 61

3.27 General Administration/Management 62

4 Document Upload Templates 64

4.1 History/Structure/Organizational Charts 64

4.2 Minimum Enrollment Waiver Request Upload Document 66

4.3 CMS State Certification Form 67

4.4 Part C Application Certification Form 83

4.5 RPPO State Licensure Table 85

4.6 RPPO State Licensure Attestation 86

4.7 RPPO Essential Hospital Designation Table 87

4.8 RPPO Essential Hospital Attestation 88

4.9 Crosswalk for Part C Quality Improvement (QI) Program 89

4.10 Crosswalk to Part C Compliance Plan 92

4.11 Partial County Justification 95

5 APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposals 97

6 APPENDIX II: Employer/Union-Only Group Waiver Plans (EGWPs) MAO “800 Series” 131

6.1 Background 131

6.2 Instructions 131

6.3 Request for Additional Waivers/Modification of Requirements (Optional) 132

6.4 Attestations 133

7 APPENDIX III: Employer/Union Direct Contract for MA 139

7.1 Background 139

7.2 Instructions 139

7.3 Request for Additional Waivers/Modification of Requirements (Optional) 140

7.4 Attestations 141

7.5 Part C Financial Solvency & Capital Adequacy Documentation For Direct Contract MAO applicants: 145

8 APPENDIX IV: Medicare Cost Plan Service Area Expansion Application 156

8.1 State Licensure 156

8.2 Service Area 158

8.3 CMS Provider Participation Contracts & Agreements 158

8.4 Contracts for Administrative & Management Services 159

8.5 Health Services Management & Delivery 161

8.6 Part C Application Certification 164

8.7 Full Financial Risk 164

8.8 Budget Forecast 164

1. GENERAL INFORMATION

1. Overview

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) significantly revised the Medicare + Choice managed care program, now called the Medicare Advantage (MA) program, and added outpatient prescription drugs to Medicare, offered by either stand-alone prescription drug plan sponsors or Medicare Advantage Organizations (MAOs). The MMA changes make managed care more accessible, efficient, and attractive to beneficiaries seeking options to meet their needs. The MA program offers several kinds of plans and health care choices, including Regional Preferred Provider Organizations (RPPOs), Private Fee-For-Service (PFFS) plans, Special Needs Plans (SNPs), and Medical Savings Account (MSA) plans.

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 have more information about those choices. The Centers for Medicare & Medicaid Services (CMS) welcomes organizations that can add value to these programs, make them more accessible to Medicare beneficiaries, and meet all the contracting requirements.

2. Types of MA Products

The MA program is comprised of a variety of product types, including:

• Coordinated Care Plans (CCPs)

• Health Maintenance Organizations (HMOs) with or without a Point of Service (POS) benefit

• Local Preferred Provider Organizations (LPPOs)

• Regional Preferred Provider Organizations (RPPOs)

• Special Needs Plans (SNPs)

• Private Fee-for-Service (PFFS) plans

• Medical Savings Account (MSA) plans

• Employer Group Waiver plans (EGWPs)

Note: For fact sheets on each of these types of product offerings, go to http://www.cms.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.

Note: The MMA requires that CCPs offer at least one MA plan that includes a Part D prescription drug benefit (MA Part D or MA-PD) in each county of its service area. To meet this requirement, the applicant must timely complete and submit a separate Part D application in connection with this Part C Application.

PFFS plans have the option to offer the Part D drug benefit. MSA plans cannot offer the Part D drug benefit.

3. Important References

MA Organizations

The following are key references about the MA program:

• Social Security Act: 42 U.S.C 1395 et seq.: http://www.ssa.gov/OP_Home/ssact/title18/1800.htm

• Medicare Regulations: 42 CFR 422:

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=4b0dbb0c0250d4508a613bbc3d131961&tpl=/ecfrbrowse/Title42/42cfr422_main_02.tpl

• Medicare Managed Care Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

• Marketing Guidelines: http://www.cms.gov/ManagedCareMarketing/

Medicare Cost Plans

Information requested in this application is based on Section 1876 of the Social Security Act (SSA) and the applicable regulations of Title XIII of the Public Health Services Act.

Additional information can be found on the Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.gov/MedicareCostPlans/

• SSA: 42 U.S.C. 1395mm:

http://www.ssa.gov/OP_Home/ssact/title18/1876.htm

• Medicare Regulations: 42 CFR 417:

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=8072f532d9936eba1bee882c805beedb&tpl=/ecfrbrowse/Title42/42cfr417_main_02.tpl

• Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.gov

4. Technical Support

CMS conducts special training sessions and user group calls for new applicants and existing contractors. All applicants are strongly encouraged to participate in these sessions, which are announced via the HPMS (see section 1.5 below) and/or the CMS main website.

CMS Central Office (CO) staff and Regional Office (RO) staff are available to provide technical support to all applicants during the application process. While preparing the application, applicants may send an email by going to https://dmao.lmi.org/ and clicking on the MA Applications tab. Please note: this is a webpage, not an email address. Applicants should contact their RO to request assistance with specific issues related to their deficiency letters. Below is a list of CMS RO contacts.

This information is also available at:

https://www.cms.gov/RegionalOffices/

RO I CMS – BOSTON REGIONAL OFFICE

John F. Kennedy Federal Building, Room 2325, 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: 212-616-2353

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 and West Virginia

RO IV CMS – ATLANTA REGIONAL OFFICE

Atlanta Federal Center, 61 Forsyth Street, 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 714, 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 Street, 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 Operations

90 7^th Street, Suite 5-300 (5w), San Francisco, CA 94103-6707

Telephone: 415-744-3602

States: Arizona, California, Guam, Hawaii, Nevada, American Samoa and The Commonwealth of Northern Mariana Islands

RO X CMS – SEATTLE REGIONAL OFFICE

Blanchard Plaza Building
2201 Sixth Avenue, MS/RX-40, Seattle, WA 98121
Telephone: (206) 615-2306

States: Alaska, Idaho, Oregon and Washington

For general information about this application, please send an email by going to: https://dmao.lmi.org/ and clicking on the MA Applications tab. Please note: this is a webpage, not an email address..

5. The Health Plan Management System (HPMS)

1. HPMS is the primary information collection vehicle through which MAOs and Medicare Cost Plan contractors will communicate with CMS during the application process, bid submission process, ongoing operations of the MA program or Medicare Cost Plan contracts, reporting and oversight activities.

2. Applicants are required to enter contact and other information collected in HPMS in order to facilitate the application review process. Applicants must promptly enter organizational data into HPMS and keep the information up to date. These requirements ensure that CMS has current information and is able to provide guidance to the appropriate contacts within the organization. In the event that an applicant is awarded a contract, this information will also be used for frequent communications during contract implementation. Therefore, it is important that this information be accurate at all times. Please note that it is CMS’ expectation that the MA and Part D Application Contact is a direct employee of the applicant.

3. HPMS is also the vehicle used to disseminate CMS guidance to MAOs and Medicare Cost Plan contractors. This information is then incorporated into the appropriate manuals. It is imperative for MAOs and Medicare Cost Plan contractors to independently check HPMS memos and follow the guidance as indicated in the memos.

1. Applicants and other interested parties, whom do not have access to HPMS, can stay abreast of current HPMS memos and guidance by subscribing to the Medicare Advantage listserv. Subscribers to the CMS PLAN or INDUSTRY listservs receive memos and guidance regarding Medicare Advantage and Part D prescription drug programs.

If you do not have access to HPMS but would like to receive CMS guidance and memos, simply request to be added to one of the following listservs:

• PLAN listserv: Choose this listserv to get HPMS guidance and memos if you are a user that works for an MA or Part D organization but your role in the company does not require HPMS access.

• INDUSTRY listserv: Choose this listserv if you are an industry user that is not associated with any existing MA or Part D organization, but work with MA and Part D in some capacity (e.g., consultants, PBMs, doctors, pharmacists, etc).

Please email your request directly to Sara Silver at Sara.Silver@cms.hhs.gov. Please indicate in the email which listserv you wish you join. If you wish to join the PLAN listserv please provide the contract number(s) you are associated with.

6. Submitting Notice of Intent to Apply (NOIA)

MA applicants

Organizations interested in offering a new MA product, expanding the service area of an existing product, or submitting a PFFS network transition application must complete a nonbinding NOIA. CMS will not accept applications from organizations that fail to submit a timely NOIA. Upon submitting the completed form to CMS, the organization will be assigned a pending contract number (H number) to use throughout the application and subsequent operational processes.

Once a contract number is assigned, the applicant should request a CMS User ID. An application for Access to CMS Computer Systems (for HPMS access) is required and can be found at: https://applications.cms.hhs.gov. 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 contract number.

Medicare Cost Plans

No initial or new 1876 Cost Plan applications can be accepted by CMS during this application cycle. CMS will accept applications to expand service areas of existing 1876 Cost Plans for 2016 in accordance with 42 CFR 417.402. During the CMS review of these applications, the most current data will be employed to apply the Cost Plan Competition Requirements with regard to this type of application. CMS will make a determination whether an application of this type cannot be processed during this application cycle to the extent that the expansion application is for a requested service area or portions of a service area in which at least two competing Medicare Advantage local coordinated care plans or two Medicare Advantage Regional PPO coordinated care plans meeting specified enrollment thresholds are available. If this is the case, the applicant will be informed and the application withdrawn from further processing and review.

Existing Cost contractors requesting service area expansions should not apply for a new Cost contract number.

7. Additional Information

1.7.A Bid Submission and Training

On or before the first Monday of June of every year, all MAOs and Medicare Cost Plan contractors offering Part D* must submit a bid, comprised of the proper benefits and pricing for each MA plan for the upcoming year based on 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. MAOs and Medicare Cost Plan contractors 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 due. Further instructions and time frames for bid submissions are provided at: http://www.cms.gov/MedicareAdvtgSpecRateStats/01_Overview.asp#TopOfPage

In order to prepare plan bids, applicants will use HPMS to define 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 or Medicare Cost Plan benefit and the BPT software to define its bid pricing information.

Once the PBP and BPT software requirements have been completed for each plan being offered, applicants will upload their bids into HPMS. Applicants will be able to submit bid uploads via HPMS on their PBP or BPT one or more times between May and the CY bid deadline, which is the first Monday in June each year. CMS will use the last successful upload received for each plan as the official bid submission.

CMS will provide technical instructions and guidance upon release of HPMS bid functionality as well as the PBP and BPT software. In addition, systems training will be available at the Bid Training in Spring 2015.

* Medicare Cost contractors are not required to offer Part D coverage but may elect to do so. A cost contractor that elects to offer Part D coverage is required to submit a Bid.

1.7.B System and Data Transmission Testing

All MAOs and Medicare Cost Plan contractors must submit information about their membership to CMS electronically and have the capability to download files or receive electronic information directly. Prior to the approval of a contract, MAOs must contact the MA Help Desk at 1-800-927-8069 for specific guidance on establishing connectivity and the electronic submission of files. Instructions are also on the MA Help Desk web page, https://www.cms.gov/mapdhelpdesk/, in the Plan Reference Guide for CMS Part C/D systems link. The MA Help Desk is the primary contact for all issues related to the physical submission of transaction files to CMS.

1.7.C Protecting Confidential Information

Applicants may seek to protect their information from disclosure under the Freedom of Information Act (FOIA) by claiming that FOIA Exemption 4 applies. The applicant is required to label the information in question “confidential” or “proprietary” and explain the applicability of the FOIA exemption it is claiming. When there is a request for information that is designated by the applicant as confidential or that could reasonably be considered exempt under FOIA Exemption 4, CMS is required by its FOIA regulation at 45 CFR 5.65(d) and by Executive Order 12600 to give the submitter notice before the information is disclosed. To decide whether the applicants information is protected by Exemption 4, CMS must determine whether the applicant has shown that: (1) disclosure of the information might impair the government's ability to obtain necessary information in the future; (2) disclosure of the information would cause substantial harm to the competitive position of the submitter; (3) disclosure would impair other government interests, such as program effectiveness and compliance; or (4) disclosure would impair other private interests, such as an interest in controlling availability of intrinsically valuable records, which are sold in the market place. Consistent with our approach under other Medicare programs, CMS would not release information that would be considered proprietary in nature if the applicant has shown it meets the requirements for FOIA Exemption 4.

1.7.D Payment Information Form

Please complete the Payment Information form that is located at:

http://www.cms.gov/MedicareAdvantageApps/Downloads/pmtform.pdf.

The document contains financial institution information and Medicare contractor data.

Please submit the fully completed Payment Information form and following documents to CMS:

• Copy of a voided check or a letter from bank confirming the routing and account information

• W-9 Form

The completed Payment Information Form and supporting documentation must be emailed to DPO_PAYMENT_ADMINISTRATOR@cms.hhs.gov by the date the completed applications are due to CMS. The subject line of the email should be “Payment Information Form for [insert contract number]”, and the plan should specify the effective date (month and year) in the body of the email.

If the applicant has questions about this form, please contact Louise Matthews at (410) 786-6903.

8. Due Dates for Applications – Medicare Advantage and Medicare Cost Plans

* Note: all dates listed below are subject to change.

Applications must be submitted by 8:00 P.M. EST, February 18, 2015. 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) and Medicare Cost Plan application review process:

APPLICATION AND BID REVIEW PROCESS  *
Date	Milestone
November 13, 2014	Recommended date by which applicants should submit their Notice of Intent to Apply Form to CMS to ensure access to Health Plan Management System (HPMS) by the date applications are released.
December 4, 2014	CMS User ID form due to CMS
January 13, 2015	Final Applications Posted by CMS
January 30, 2015	Deadline for NOIA form submission to CMS
February 18, 2015	Completed Applications due to CMS
April 2015	Plan Creation module, Plan Benefit Package (PBP), and Bid Pricing Tool (BPT) available on HPMS.
Mid to End of May 2015	Health Plan Management System (HPMS) formulary submission window.
May 2015	PBP/BPT Upload Module available on HPMS
June 1, 2015 *First Monday in June	Bids due to CMS.
Late August 2015	CMS completes review and approval of bid data.
September 2015	CMS executes MA and MA-PD contracts with organizations whose bids are approved and who otherwise meet CMS requirements.
Mid October 2015	Annual Coordinated Election Period begins for CY 2016 plans.

* Note: all dates listed above are subject to change.

9. Request to Modify a Pending Application

Applicants seeking to withdraw or reduce the service area of a pending application (i.e., one being reviewed by CMS) must submit a written request to CMS on the organization’s letterhead and signed by an authorized corporate official. All requests are due to CMS no later than fifteen days after the issuance of the Notice of Intent to Deny (NOID) letter. 

Applicants may submit the request using any of the following methods:

1. Email - Send the request in PDF format as an attachment to the email message by going to https://dmao.lmi.org/ and clicking on the MA Applications tab. Please note: this is a webpage, not an email address. Send a copy of the letter via e-mail to the Regional office Account Manager or Application reviewer.

2. Mail – Address the request to:

CMS

Attn: MCAG/DMAO

Mail Stop: C4-22-04

7500 Security Blvd.

Baltimore, MD 21244

Mail a copy of the request to the Regional Office Account Manager or Application Reviewer.

3. Fax - Send faxed requests to the attention of the Part C Applications Operations Manager at (410) 786-8933. Fax a copy to the Regional Office Account Manager or Application Reviewer.

 

The following information must be included in the request:

 

• Applicant Organization’s Legal Entity Name

• Full and Correct Address and Point of Contact information for follow-up, if necessary

• Contract Number (H#)

• Reason for withdrawal

• Exact Description of the Nature of the Withdrawal, for example:

• Withdrawal from individual Medicare market counties (keeping Medicare employer group counties, e.g., 800 series plan(s))

• Withdrawal from employer group counties (keeping the individual Medicare market counties)

• Withdrawal of the entire application.

• Withdrawal of specifically named counties from both individual Medicare and employer group markets

10. Application Determination and Appeal Rights

All applicants

If CMS determines that the applicant is not qualified and denies this application, the applicant has the right to appeal this determination through a hearing before a CMS Hearing Officer. Administrative appeals of MA-PD application denials are governed by 42 CFR 422, Subpart N. The request for a hearing must be in writing, signed by an authorized official of the applicant organization, and received by CMS within 15 calendar days from the date CMS notifies the MAO of its determination (see 42 CFR 422.662.) If the 15^th day falls on a weekend or federal holiday, the applicant has until the next regular business day to submit its request.

The appealing organization must receive a favorable determination resulting from the hearing or review as specified under Part 422, Subpart N prior to September 1, 2015 (tentative date) in order to qualify for a Medicare contract to begin January 1, 2016.

2. INSTRUCTIONS

1. Overview

Applicants must complete the 2016 MA or Medicare Cost Plan Service Area Expansion application using HPMS as instructed. CMS will only accept submissions using this current 2016 version 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 certifying that its organization complies with the relevant requirements as of the date the application is submitted to CMS, unless a different date is stated by CMS.

CMS may verify an applicants readiness and compliance with Medicare requirements through on-site visits at the applicants facilities as well as through other program monitoring techniques throughout the application process, as well as at any time both prior to and after the start of the contract year. Failure to meet the requirements represented in this application and to operate MA or Medicare Cost plans consistent with the applicable statutes, regulations, and the MA or Medicare Cost Plan contract, and other CMS guidance could result in the suspension of plan marketing and enrollment. If these issues are not corrected in a timely manner, the applicant will be disqualified from participation in the MA or Medicare Cost Plan program, as applicable.

Throughout this application, applicants are asked to provide various documents and/or tables in HPMS. There is a summary of all documents required to be submitted at the end of each attestation section.

CMS strongly encourages MA applicants to refer to the regulations at 42 CFR 422 while Medicare Cost Plan applicants should refer to the regulations at 42 CFR 417 to clearly understand the nature of the requirements in order to provide an appropriate submission. Nothing in this application is intended to supersede the regulations at 42 CFR 422 or 42 CFR 417. Failure to reference a regulatory requirement in this application does not affect the applicability of such requirement, and applicants are required to comply with all applicable requirements of the regulations in Part 422 or 417 of Title 42 of the CFR. Applicants must read HPMS memos and visit the CMS web site periodically to stay informed about new or revised guidance documents.

2. Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans (EGWPs)

Applicants who wish to offer MA or MA-PD products under Employer/Union-Only Group Waivers must complete and timely submit a separate EGWP application. Please see APPENDIX II: Employer/Union-Only Group Waiver Plans (EGWPs) MAO “800 Series” of this application for details about EGWPs.

All applicants will be able to enter their EGWP service areas directly into HPMS during the application process (refer to HPMS User Guide). Applicants may provide coverage to employer group members wherever they reside (i.e., nationwide). However, in order to provide coverage to retirees wherever they reside, applicants must set their service area to include all areas where retirees reside during the plan year (i.e., national service areas).

3. Applicants Seeking to Offer Employer/Union Direct Contract MAO

Applicants who wish to offer an Employer/Union Direct Contract Private Fee-For Service (PFFS) MAO must complete and timely submit a separate EGWP application. Please see APPENDIX III: Employer/Union Direct Contract for MA of this application for details about the Direct Contract MAO.

In general, MAOs can cover beneficiaries only in the service areas in which they are state licensed and approved by CMS to offer benefits. CMS has waived these requirements for Direct Contract MAOs. Direct Contract MAO applicants can extend coverage to all of their Medicare-eligible active members/retirees regardless of whether they reside in one or more MAO regions in the nation. In order to provide coverage to retirees wherever they reside, Direct Contract MAO applicants must set their service area to include all areas where retirees may reside during the plan year. CMS will not permit mid-year service area expansions.

Direct Contract MAOs that offer Part D coverage (i.e., MA-PDs) will be required to submit pharmacy access information for the entire defined service area during the application process and demonstrate sufficient access in these areas in accordance with employer group waiver pharmacy access policy.

4. Applicants Seeking to Offer Special Needs Plans (SNPs)

New and expanding SNPs must also complete and timely submit a separate SNP proposal. Existing SNPs that require re-approval under the NCQA SNP Approval process should only submit their Model of Care written narrative and Model of Care Matrix Upload Document. These SNPs will not be required to submit any other portion of the MA application or SNP proposal, unless specifically noted (e.g., in the instructions for submission of contracts with State Medicaid Agencies). Please refer to APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposals for specific instructions and details.

Existing Dual Eligible SNPs will need to submit a signed and executed State Medicaid Agency Contract in HPMS without submitting any other portion of the SNP proposal unless the existing D-SNP is changing its D-SNP subtype or applying for a Service Area Expansion.

5. Applicants Seeking to Offer Medicare Cost Plans

All 2016 applicants seeking to expand the service area of an existing Medicare Cost Plan must complete and timely submit a separate Medicare Cost Plan application. Please refer to APPENDIX IV: Medicare Cost Plan Service Area Expansion Application for application instructions and details.

6. Applicants Seeking to Serve Partial Counties

Applicants seeking to serve less than a full county (i.e., a partial county) must enter all service area information in HPMS by the application submission deadline. Applicants cannot introduce a partial county request after the initial application submission. In other words, applicants cannot reduce a full-county request to a partial county request during the application review period.

7. Types of Applications

Initial Applications are for:

• Applicants who are seeking an MA contract to offer an MA product for the first time or to offer an MA product they do not already offer.

• Existing MA Organizations who are seeking an MA contract to offer a type of MA product they do not currently offer.

• Existing PFFS contractors who are required to transition some or all of their service area to a network based product.

Note: An RPPO applicant may apply as a single entity or as a joint enterprise. Joint Enterprise applicants must provide as part of their application a copy of the agreement executed by the State-licensed entities describing their rights and responsibilities to each other and to CMS in the operation of a Medicare Part D benefit plan. Such an agreement must address at least the following issues:

• Termination of participation in the joint enterprise by one or more of the member organizations; and

• Allocation of CMS payments between/among the member organizations.

Service Area Expansion Applications are for:

• Existing MAO contractors who are seeking to expand the service area of an existing contract number.

8. Chart of Required Attestations by Type of Applicant

This chart (Chart 1) describes the required attestations that must be completed for each type of application and applicant. The purpose of this chart is to provide the applicant with a summary of the attestation topics. First, the applicant must determine if the application will be an initial or service area expansion type. Then the applicant must select the type of MA product it will provide. The corresponding location of each attestation is provided under the column labeled “Section #,” which corresponds to this application package.

Chart 1 - Required Attestations by Type of Application

Attestation Topic	Section #	Initial Applicants					Service Area Expansion
		CCP	PFFS	RPPO	MSA		CCP	PFFS	RPPO	MSA
Experience and Organizational History	3.1	X	X	X	X
Administrative Management	3.2	X	X	X	X
State Licensure	3.3	X	X	X	X		X	X	X	X
Program Integrity	3.4	X	X	X	X
Compliance Plan	3.5	X	X	X	X
Key Management Staff	3.6	X	X	X	X
Fiscal Soundness	3.7	X	X	X	X
Service Area	3.8	X	X	X	X		X	X	X	X
CMS Provider Participation Contracts & Agreements	3.9	X	X	X	X		X	X	X	X
Contracts for Administrative & Management Services	3.10	X	X	X	X		X	X	X	X
Health Services Management & Delivery	3.11	X	X	X	X		X	X*	X	X*
Quality Improvement Program	3.12	X	X	X	X
Marketing	3.13	X	X	X	X
Eligibility, Enrollment, and Disenrollment,	3.14	X	X	X	X
Working Aged Membership	3.15	X	X	X	X
Claims	3.16	X	X	X	X
Communications between MAO and CMS	3.17	X	X	X	X
Grievances	3.18	X	X	X	X
Appeals	3.19	X	X	X	X
Health Insurance Portability and Accountability Act of 1996 (HIPPA)	3.20	X	X	X	X
Continuation Area	3.21	X	X	X	X		X	X		X
Part C Application Certification	3.22	X	X	X	X		X	X	X	X
RPPO Essential Hospital	3.23			X					X
Access to Services	3.24		X		·			X		·
Claims Processing	3.25		X		X			X		X
Payment Provisions	3.26		X		X			X		X
General Administration/Management	3.27				X					X

*Indicates applicants with a network

·Indicates that applicants are not required to complete attestations but must upload selected information, as required, in HPMS system.

9. Health Services Delivery (HSD) Tables Instructions

Applicants are required to demonstrate network adequacy through the submission of HSD Tables. Detailed instructions on how to complete each of the required HSD Tables are available in a separate file along with the HSD Table templates. The HSD instructions and table templates are available in the MA Download file in HPMS.

As part of the application module in HPMS, CMS will be providing applicants with an automated tool for submitting network information via HSD tables. The tables will then be reviewed automatically against default adequacy measures for each required provider type in each county. This process will permit applicants to determine if they have achieved network adequacy before finalizing their application. Further, CMS will make these default values known prior to the opening of the application module. As such, applicants will see the values (providers and facilities of each required type in each county) that CMS requires before the application module opens. Applicants who believe that CMS default values for a given provider type in a given county are not in line with local patterns of care may seek an exception, in which case the applicant will submit required information to support the exception request(s). The HSD exception review will occur manually by a CMS reviewer as it has in the past. Applicants who submit HSD tables that 'clear' CMS's default values will still be required to submit signed contracts and other documents that demonstrate the accuracy of the HSD table submissions. Applicants may still be determined to have network deficiencies even if they 'pass' the automated review.

CMS will be providing training to applicants on the automated system, the HSD tables, and the default values for determining network adequacy after the application module opens, and expects to annually post the default values for determining network adequacy in the Fall of each year.

Application forms and tables associated with the applications are available in separate Microsoft Word or Excel files that are available at: http://www.cms.gov/MedicareAdvantageApps/. Microsoft Word files located on the CMS web site are posted in a .zip format and can also be found in the MA Download file in HPMS.

Applicants must submit separate completed copies of each table template for each area/region or county that the applicant is requesting. Specific instructions on how to complete and submit each table will be outlined in the 2016 HPMS User Guide for the Part C Application. 

10. Document (Upload) Submission Instructions

MA applicants must include their assigned H number in the file name of all submitted documents. Medicare Cost Plan Service Area Expansion applicants should use their existing H number in the file name of all submitted documents. Applicants are encouraged to be descriptive in naming all files. If the applicant is required to provide multiple versions of the same document, the applicant should insert a number, letter, or even the state name at the end of each file name for easy identification (see the Application Readme.file).

11. MA Part D (MA-PD) Prescription Drug Benefit Instructions

The Part D Application for MA-PD applicants is an abbreviated version of the application used by stand-alone Prescription Drug Plan (PDPs), as the regulation allows CMS to waive provisions that are duplicative of MA requirements or where a waiver would facilitate the coordination of Part C and Part D benefits. Further, the Part D Application for MA-PD applicants includes a mechanism for applicants to request CMS approval of waivers for specific Part D requirements under the authority of 42 CFR 423.458(b)(2). The Part D Application for MA-PD applicants can be found at: http://www.cms.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage. Specific instructions to guide MA-PD applicants in applying to offer Part D benefits during 2016 are provided in the Part D Application for MA-PD applicants and must be followed.

Note: Failure to file the required Part D Application for MA-PD applicants will render the MA-PD Application incomplete and could result in the denial of this application.

Failure to submit 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 (NOID) or a Notice of Denial.

2. ATTESTATIONS

1. Experience & Organization History

The purpose of this section is to allow applicants to submit information describing their experience and organizational history. A description of the MAO’s structure of ownership, subsidiaries, and business affiliations will enable CMS to more fully understand additional factors that contribute to the management and operation of MA plans.

An organization must meet minimum enrollment requirements in order to hold a Medicare Advantage contract with CMS (see 42 CFR 422.514).  The minimum enrollment requirement is an indicator that the organization applying for a Medicare Advantage contract is able to handle risk and capitated payments.  CMS expects that an organization is able to effectively manage a health care delivery system including the enrollment and disenrollment of members and the timely payment of claims, provide quality assurances, and have systems to handle grievances and appeals. 

CMS recognizes that new applicants may believe they are capable of administering and managing an MA contract although they do not meet the minimum enrollment requirements. CMS also recognizes that there may be reasonable factors, such as specific populations served or geographic location that might result in a plan having low enrollment. For example, SNPs may legitimately have low enrollment because of their focus on a subset of enrollees with certain medical conditions. Such organizations and new applicants may submit a request to waive the enrollment requirements.

The following attestations were developed to implement the regulations of 42 CFR 422.502(b), d 422.503(b) and 422.514.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: EXPERIENCE & ORGANIZATIONAL HISTORY	YES	NO	N/A
Is the applicant applying to be the same type of organization as indicated on the applicants NOIA? The applicant may verify its organization type by looking at the Contract Management Basic page. If the type of organization the applicants organization intends to offer has changed, do not complete this application. Send an email by going to https://dmao.lmi.org/ and clicking on the MA Applications tab. Please note: this is a webpage, not an email address. Please indicate in the pending contract number and the type of organization for which the applicant is now seeking to apply in the email.
The Medicare Advantage plan(s) currently offered by the applicant, applicants parent organization, or subsidiary of the applicants parent organization has been operational since January 1, 2014 or earlier. (If the applicant, applicants parent organization, or a subsidiary of applicants parent organization does not have any existing contracts with CMS to operate a Medicare Advantage Plan, select “NA”.)
The applicant attests that it has at least 5,000 individuals enrolled for the purpose of receiving health benefits from the organization; or it has at least 1,500 individuals enrolled for purposes of receiving health benefits from the organization and the organization primarily serves individuals residing outside of urbanized areas as defined in §412.62(f)). If the applicant attests No, the applicant must submit a Minimum Enrollment Waiver Request by uploading the Minimum Enrollment Waiver Request Upload Document and any supporting documentation. Note: The applicant may count members enrolled in other risk based health insurance products offered by the organization (e.g., commercial, Medicaid). Note: CMS will provide any Minimum Enrollment Waiver review related deficiencies to applicants in the Notice of Intent to Deny.

2. In HPMS, upload the History/Structure/Organizational Charts. This is a brief summary of the applicants history, structure and ownership. Include organizational charts to show the structure including ownership, subsidiaries, and business affiliations.

3. In HPMS, upload a Minimum Enrollment Waiver Request Upload Document and any supporting documentation if you attested “No” to question 3.1.3.

2. Administrative Management

The purpose of the administrative management attestations is to ensure that MAOs have the appropriate resources and structures available to effectively and efficiently manage administrative issues associated with Medicare beneficiaries. CMS requires that MA plans have sufficient personnel and systems to organize, implement, control, and evaluate financial and marketing activities, oversee quality assurance, and manage the administrative aspects of the organization. The following attestations were developed to implement the regulations of 42 CFR 422.503(b)(4)(ii).

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ADMINISTRATIVE MANAGEMENT	YES	NO
A contract of the applicant has been non-renewed or terminated within the past 2 years. • If “Yes”, do not continue and contact CMS by sending an email to https://dmao.lmi.org/ and clicking on the MA Applications tab. Please note: this is a webpage, not an email address.
The applicant currently operates a CMS Cost contract under Section 1876 of the SSA in some or all of the intended service area of this application.
The applicant offers health plan products to a commercial population.
The applicant currently has administrative and management arrangements that feature a policy making body (e.g., board of directors) exercising oversight and control over the organization’s policies and personnel (e.g., human resources) to ensure that management actions are in the best interest of the organization and its enrollees.
The applicant currently has administrative and management agreements that feature personnel systems sufficient for the organization to organize, implement, control and evaluate financial and marketing activities, quality assurance, and the administrative aspects of the organization.
The applicant currently has administrative and management agreements that feature an executive manager / chief executive officer whose appointment and removal are under the control of the policy-making body.

3. State Licensure

To ensure that all MAOs operate in compliance with state and federal regulations, CMS requires MAOs to be licensed under state law. This requirement will ensure that MAOs adhere to state regulations aimed at protecting Medicare beneficiaries. The following attestations were developed based on the regulations at 42 CFR 422.400.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE	YES	NO	N/A
Applicant is licensed under state law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each state in which the applicant proposes to offer the managed care product. In addition, the scope of the license or authority allows the applicant to offer the type of managed care product that it intends to offer in the state or states. If “Yes”, upload in HPMS an executed copy of a state license certificate and the CMS State Certification Form for each state being requested. Note: Applicant must meet and document all applicable licensure and certification requirements no later than the applicants final upload opportunity, in response to CMS’ NOID communication.
Applicant is a Joint Enterprise. If “Yes”, upload the copy of the Joint Enterprise agreement executed by the state-licensed entities.
Applicant is licensed under state law as a risk-bearing entity eligible to offer health insurance or health benefits in at least one state in the RPPO region, and if not licensed in all states, the applicant has applied for additional state licenses for the remaining states in the RPPO regions. In addition, the scope of the license or authority allows the applicant to offer the type of MA plan that it intends to offer in the state or states. If “Yes”, upload in HPMS an executed copy of a state license certificate and the CMS State Certification Form for each state being requested or the RPPO State Licensure Attestation for MA RPPOs and a complete RPPO State Licensure Table for each MA Region, if applicant is not licensed in all states within the region. Note: Applicant must meet and document all applicable licensure and certification requirements no later than the applicants final upload opportunity, which is in response to CMS’ NOID communication. Note: Joint Enterprise applicants must submit state certification forms for each member of the enterprise.
Applicant is currently under some type of supervision, corrective action plan or special monitoring by the state licensing authority in any state. This means that the applicant has to disclose actions in any state against the legal entity which filed the application. If “Yes”, upload in HPMS an explanation of the specific actions taken by the state licensing authority.
Applicant conducts business as "doing business as" (d/b/a) or uses a name different than the name shown on its Articles of Incorporation.  If “Yes”, upload in HPMS a copy of the state approval for the d/b/a.
For states or territories whose license(s) renew after the first Monday in June, applicant agrees to (1) upload, in addition to the current license, a copy of its completed license renewal application or other documentation (e.g., invoice from payment of renewal fee) to show that the renewal process is being completed in a timely manner, and (2) electronically send a copy of the renewed license to the CMS Regional Office Account Manager promptly upon issuance and no later than 12/31/15. Note: If the applicant does not have a license that renews after the first Monday in June, then the applicant should respond "N/A".

2. In HPMS, upload an executed copy of the State License Certificate and the CMS State Certification Form for each state being requested, if applicant answers “Yes” to the corresponding question above.

3. In HPMS, upload a copy of the current State Licensure Certificate and a copy of the completed license renewal application or other documentation (e.g., invoice from payment of renewal fee), if applicant answers “Yes” to the statement regarding the current license renewal date falling after the first Monday in June.

4. In HPMS, upload a copy of the Joint Enterprise agreement executed by the state-licensed entities, if applicant answers “Yes” to the corresponding question above.

5. In HPMS, upload executed copy of the RPPO State Licensure Attestation for MA RPPOs and a complete RPPO State Licensure Table for each MA Region, if applicant is not licensed in all states within the region and answers “Yes” to the corresponding question above.

6. In HPMS, upload the State Corrective Plans / State Monitoring Explanation (as applicable), if applicant answers “Yes” to the corresponding question above.

7. In HPMS, upload the State Approval for d/b/a, if applicant answers “Yes” to the corresponding question above.

Note: Federal Preemption Authority – The MMA amended section 1856(b)(3) of the SSA and significantly broadened the scope of Federal preemption of state law. The revised MA regulations’ at 42 CFR 422.402 states that MA standards supersede state law or regulation with respect to MA plans other than licensing laws and laws relating to plan solvency.

4. Program Integrity

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: BUSINESS INTEGRITY	YES	NO
Applicant, applicant staff, and its affiliated companies, subsidiaries or subcontractors (first tier, downstream, and related entities), and subcontractor staff agree that they are bound by 2 CFR 376 and attest that they are not excluded by the Department of Health and Human Services Office of the Inspector General or by the General Services Administration exclusion lists. Please note that this includes any member of the board of directors and any key management or executive staff or any major stockholder.

5. Compliance Plan

The purpose of a compliance plan is to ensure that the MAO, including but not limited to compliance officers, organization employees, contractors, managers and directors, abides by all federal and state regulations, standards, and guidelines. To accomplish this objective, the plan should include the following components: training/education, communication plan, disciplinary standards, internal monitoring/auditing procedures, etc. The following information was developed to implement the regulations of 42 CFR 422.503(b)(4)(vi).

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMPLIANCE PLAN	YES	NO
Applicant has a compliance plan that is ready for implementation.

2. If you are applying as a MA-only non-network organization (i.e. PFFS or MSA), in HPMS, upload a copy of the applicants Medicare Part C Compliance Plan in an Adobe.pdf format.

Note: The Part C compliance plan must be developed in accordance with 42 CFR 422.503(b)(4)(vi). The compliance plan must demonstrate that all seven elements in the regulation and in Chapter 21 of the Medicare Managed Care Manual (MMCM) are implemented and specific to the issues and challenges presented by the Part C program.

3. If you are applying as a MA-only non-network organization (i.e. PFFS or MSA) in HPMS, complete and upload the Crosswalk for Part C Compliance Plan document.

6. Key Management Staff

The purpose of this section is to ensure that qualified staff is available to support the MAO. An organizational chart showing the relationships of the various departments will demonstrate that the MAO meets this requirement. The following attestations were developed to implement the regulations of 42 CFR 422.503(b)(4)(ii).

In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: KEY STAFF MANAGEMENT	YES	NO
Applicant attests that all staff is qualified to perform their respective duties.
Applicant attests that they have completed the Contact Management/Information/Data page in HPMS.

2. In HPMS, upload organizational charts showing the relationship of various departments.

7. Fiscal Soundness

1. In HPMS, complete the table below:

YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: FISCAL SOUNDNESS	YES	NO
Applicant maintains a fiscally sound operation and maintains a positive net worth (Total Assets exceed Total Liabilities).

2. In HPMS, upload the most recent Audited Financial Statements that is available and the most recent Quarterly NAIC Health Blank or other form of quarterly financials if the NAIC Health Blank is not required by your state. CMS reserves the right to request additional financial information as it sees fit to determine if the applicant is maintaining a fiscally sound operation.

Note: If the applicant was not in business in 2013, and has less than six months of operation in 2014, it must electronically upload the financial information it submitted to the state at the time the state licensure was requested. If the applicant has a parent company, it must submit the parent’s 2014 Audited Financial Statement. If the parent’s 2014 Audited Financial Statement is not available at the time of the submission of the application, the applicant must submit the parent’s 2013 Audited Financial Statement and the parent’s 2014 Annual NAIC Health Blank or other form of quarterly financials if the NAIC Health Blank is not required by your State.

8. Service Area

The purpose of the service area attestation is to clearly define which areas will be served by the MAO. A service area for local MA plans is defined as a geographic area composed of a county or multiple counties, while a service area for MA regional plans is a region approved by CMS. The following attestation was developed to implement the regulations of 42 CFR 422.2.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: SERVICE AREA	YES	NO
Applicant meets the county integrity rule as outlined in Chapter 4 of the MMCM and will serve the entire county. If "No", complete CMS’ Partial County Justification document.

Note: Applicant may only designate or request a partial county service area during the initial application submission.

2. In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area the applicant proposes to serve. Applicants that do not meet the county integrity rule and applying for a partial county must complete CMS’ Partial County Justification document.

9. CMS Provider Participation Contracts & Agreements

This section contains attestations that address the requirements of 42 CFR 422.504, which require that MAOs have oversight for contractors, subcontractors, and other entities. The intent of the regulations is to ensure services provided by these parties meet contractual obligations, laws, regulations, and CMS instructions. The MAO is held responsible for the compliance of its providers and subcontractors with all contractual, legal, regulatory, and operational obligations. Beneficiaries shall be protected from payment or fees that are the obligation of the MAO. Further guidance is provided in Chapter 11 of the MMCM.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PROVIDER CONTRACTS AND AGREEMENTS	YES	NO
Applicant agrees to comply with all applicable provider requirements in subpart E of this part, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers, and limits on physician incentive plans. 42 CFR 422.504(a)(6)
Applicant agrees that all provider and supplier contracts or agreements contain the required contract provisions that are described in the Medicare Managed Care Manual, and CMS regulations at 42 CFR 422.504.
Applicant has or will have executed provider, facility, and supplier contracts in place to demonstrate adequate access and availability of covered services throughout the requested service area.
Applicant agrees to have all provider contracts and/or agreements available upon request.
Applicant has executed “CMS Medicare Advantage Contract Amendments” with ALL of its contracted providers and facilities (first tier contracts and downstream contracts at every level).
Applicant has executed “CMS Medicare Advantage Contract Amendments” with SOME of its contracted providers and facilities (first tier contracts and downstream contracts at every level).
Applicant has executed “CMS Medicare Advantage Contract Amendments” with NONE of its contracted providers and facilities (first tier contracts and downstream contracts at every level).

10. Contracts for Administrative & Management Services

This section describes the requirements the applicant must demonstrate to ensure that any contracts for administrative/management services comply with the requirements of all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 422.504(i)(4)(v). Further guidance is provided in Chapter 11.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE MANAGEMENT SERVICES	YES	NO
Applicant has contracts with related entities, contractors and subcontractors (first tier, downstream, and related entities) to perform, implement or operate any aspect of MA operations for the MA contract.
Applicant verifies that it has entered accurate information related to the delegated entities and their functions in the HPMS Delegated Business Function Table in HPMS.
Applicant agrees that as it implements, acquires, or upgrades health information technology (HIT) systems, where available, the HIT systems and products will meet standards and implementation specifications adopted under section 3004 of the Public Health Services Act as added by section 13101 of the American Recovery and Reinvestment Act of 2009, P.L. 111-5.
Applicant agrees that all contracts for administrative and management services contain the required contract provisions that are described in the MMCM, and the CMS contract requirements in accordance with 42 CFR 422.504.

2. In HPMS, enter the Delegated Business Functions under the Part C Data Link.

Note: If the applicant plans to delegate a specific function but cannot at this time name the entity with which the applicant will contract, enter "Not Yet Determined" so that CMS is aware of the applicants plans to delegate that function. If the applicant delegates a particular function to a number of different entities (e.g., claims processing to multiple medical groups), then list the five most significant entities for each delegated business function identified and in the list for the sixth, enter "Multiple Additional Entities".

11. Health Services Management & Delivery

The purpose of the Health Service Management and Delivery attestations is to ensure that all applicants deliver timely and accessible health services for Medicare beneficiaries. CMS recognizes the importance of ensuring continuity of care and developing policies for medical necessity determinations. Therefore, MAOs will be required to select, evaluate, and credential providers that meet CMS’ standards, in addition to ensuring the availability of a range of providers necessary to meet the health care needs of Medicare beneficiaries. The following attestations were developed to implement the regulations of 42 CFR 422.112, and 422.114.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH SERVICES MANAGEMENT AND DELIVERY	YES	NO
Applicant agrees to establish, maintain, and monitor the performance of a comprehensive network of providers to ensure sufficient access to Medicare covered services as well as supplemental services offered by the MAO in accordance with written policies, procedures, and standards for participation established by the MAO. Participation status will be revalidated at appropriate intervals as required by CMS regulations and guidelines.
Applicant has executed written agreements with providers (first tier, downstream, or other entity instruments) structured in compliance with CMS regulations and guidelines.
Applicant, through its contracted or deemed participating provider network, along with other specialists outside the network, community resources or social services within the MAO’s service area, agrees to provide ongoing primary care and specialty care as needed and guarantee the continuity of care and the integration of services through: Prompt, convenient, and appropriate access to covered services by enrollees 24 hours a day, 7 days a week; The coordination of the individual care needs of enrollees in accordance with policies and procedures as established by the applicant; Enrollee involvement in decisions regarding treatment, proper education on treatment options, and the coordination of follow-up care; Effectively addressing and overcoming barriers to enrollee compliance with prescribed treatments and regimens; and Addressing diverse patient populations in a culturally competent manner.
Applicant agrees to establish policies, procedures, and standards that: Ensure and facilitate the availability, convenient and timely access to all Medicare covered services as well as any supplemental services offered by the MAO; Ensure access to medically necessary care and the development of medically necessary individualized care plans for enrollees; Promptly and efficiently coordinate and facilitate access to clinical information by all providers involved in delivering the individualized care plan of the enrollee; Communicate and enforce compliance by providers with medical necessity determinations; and Do not discriminate against Medicare enrollees.
Applicant has verified that contracted providers included in the MA Facility Table are Medicare certified and the applicant certifies that it will only contract with Medicare certified providers in the future.
Applicant agrees to provide all services covered by Medicare Part A and Part B and to comply with CMS national coverage determinations, general coverage guidelines included in Original Medicare manuals and instructions, and the written coverage decisions of local Medicare contractors with jurisdiction for claims in the geographic service area covered by the MAO.
Applicant agrees that all “applicable” contracted physicians/providers listed in the Provider Table have admitting privileges, as appropriate, (other than courtesy privileges) at a contracted facility.
Applicant agrees that it will provide all medically necessary transplant services to its Medicare enrollees in full agreement with the CMS guidance found in Chapter 4, Benefits and Beneficiary Protections, Medicare Managed Care Manual (Rev. 115, 08-23-13) at 10.11.
Applicants offering coordinated care plans agree that when providing transplant services at clinical locations outside of the plan’s service area, in accordance with the provisions of Chapter 4, Benefits and Beneficiary Protections, Medicare Managed Care Manual (Rev. 115, 08-23-13) at 10.11, the applicant will arrange for and pay for reasonable accommodation and transportation for the enrollee/patient and a companion.

B. In HPMS, upload the following completed HSD tables:

• MA Provider Table

• MA Facility Table

12. Quality Improvement Program

The purpose of this section is to ensure that all applicants have a Quality Improvement Program (QI) Program. A QI Program will ensure that MAOs have the infrastructure available to increase quality, performance, and efficiency of the program on an on-going basis, and will help identify actual or potential triggers or activities for the purpose of mitigating risk and enhancing patient safety. This process will provide MAOs an opportunity to resolve identified areas of concern. The following attestations were developed to implement the regulations of 42 CFR 422.152 and Chapter 5 of the MMCM.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: QIP	YES	NO
Applicant has an ongoing QI Program that is ready for implementation. 42 CFR 422.152(a)
Applicant agrees to provide CMS with all documents pertaining to the QI Program upon request.

2. In HPMS, upload a copy of the applicants QI Program in an Adobe.pdf format.

3. In HPMS, complete and upload the Crosswalk for Part C QI Program.

13. Marketing

The purpose of the Medicare Operations Marketing attestations is to ensure that all applicants comply with all CMS regulations and guidance including, but not limited to, the Managed Care Manual, user guides, the annual Call Letter, and communications through HPMS. Medicare Advantage MA and Cost Plans are required to provide comprehensive information in written form and via a call center to ensure that Medicare beneficiaries understand the features of their MA plans. The following attestations were developed to implement the regulations of 42 CFR 422.2260 through 422.2276.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MEDICARE OPERATIONS – MARKETING	YES	NO	N/A
Applicant complies with marketing guidelines and approval procedures that are contained in Chapter 3 of the Medicare Managed Care Manual and posted on the www.cms.gov/ website, including the requirements of the File and Use Certification process.
Applicant agrees to make available to beneficiaries those marketing materials, notices, and other standardized letters and forms that comply with CMS marketing requirements.
Annually and at the time of enrollment, the applicant agrees to provide enrollees information about the following features, as described in the marketing guidelines: Enrollment Instruction Forms (Enrollment Kit-at the time of enrollment) Beneficiary Procedural Rights Potential for Contract Termination Summary of Benefits (Enrollment Kit-at the time of enrollment and upon request) Annual Notice of Change (ANOC)/Evidence of Coverage (EOC) Premiums Service Area Provider Directory Plan ratings information Membership ID Card (required at the time of enrollment and as needed or required by plan sponsor post-enrollment)
Applicant agrees to provide general coverage information, as well as information concerning utilization, grievances, appeals, exceptions, quality assurance, and financial information to any beneficiary upon request.
The applicant agrees to verify the identity of the caller as a beneficiary or validate the authority of the caller to act on behalf of the beneficiary prior to discussing any Personal Health Information as required under HIPAA.
Applicant agrees to maintain a toll-free customer service call center that provides customer telephone service to current and prospective enrollees in compliance with CMS standards. This means the applicant complies with the following: Call center operates during normal business hours, seven days a week from 8:00 AM to 8:00 PM for all time zones of the applicants respective service areas. A customer service representative is available to answer beneficiary calls directly during the annual enrollment and 45 days after the annual enrollment period. On Saturdays, Sundays, and holidays, from February 15th until the following annual enrollment period, a customer service representative or an automated phone system may answer beneficiary calls. If a beneficiary is required to leave a message in voice mail box due to the utilization of an automated phone system, the applicant ensures that a return call to a beneficiary is made in a timely manner, but no later than one business day after receipt of the message. Call center must provide interpreter service to all non-English speaking, or limited English proficient (LEP) beneficiaries.
Applicant agrees to provide Toll Free TTY or TDD numbers for all hearing impaired beneficiaries in conjunction with all other phone numbers utilized for call center activity.
Applicant agrees to make the marketing materials specified by CMS available in any language that is the primary language of at least 5% of a plan sponsor’s benefit package service area. NOTE: Plan sponsors operating in service areas that do not meet the 5% threshold are not required to produce any translated materials.
The applicant agrees to operate a toll-free call center to respond to physicians and other providers requesting exceptions, coverage determinations, prior authorizations, and beneficiary appeals. This means the applicant complies with the following: The call center must be available to callers from 8:00 am to 6:00 pm, consistent with the local time zone of each of the applicants respective service areas, Monday through Friday, at a minimum. An alternative technology, such as an interactive voice response system or voice mail, may be used outside of these hours, ensuring that information may be submitted for action by the applicant 24 hours a day, 7 days a week.
The applicant agrees to comply with CMS performance requirements for all call centers including: The average hold time for a beneficiary to reach a customer service representative is two minutes or less. Eighty percent (80%) of all incoming calls are answered within 30 seconds. The disconnect rate for all incoming customer calls does not exceed 5%. Acknowledgement of all calls received via an alternative technology within one business day.
Applicant agrees to guarantee that all call center staff are effectively trained to provide thorough, accurate, and specific information on all MA product offerings, including applicable eligibility requirements, cost sharing amount, premiums, and provider networks.
Applicant agrees to implement and maintain an explicit process for handling customer complaints.
Applicant agrees to develop and maintain an Internet Web site providing thorough, accurate, and specific information as specified by CMS.
Applicant agrees to provide initial and renewal compensation to a broker or agent for the sale of a Medicare health plan consistent with CMS requirements.
Applicant agrees that brokers and agents selling Medicare products are trained and tested, annually, on Medicare rules and regulations and the specifics of the plans they are selling, and that they pass with a minimum score as specified in CMS guidance.

14. Eligibility, Enrollment, and Disenrollment

This section identifies attestations consistent with the requirements of 42 CFR 422.50 through 422.74, which address the eligibility requirements to enroll in, continue enrollment in, or disenroll from an MA plan. The intent of these regulations is to ensure that all MAOs fully comply with the requirements set forth to ensure services adhere to standard processes and meet contractual obligations, laws, regulations and CMS instructions.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MEDICARE OPERATIONS – ELIGIBILITY, ENROLLMENT and DISENROLLMENT	YES	NO
Applicant agrees to comply with all CMS regulations and guidance pertaining to eligibility, enrollment and disenrollment for MA, including, but not limited to, the MMCM, user guides, the annual Call Letter, and interim guidance and other communications distributed via HPMS.
Applicant agrees to provide required notices to beneficiaries, including pre-enrollment and post-enrollment materials, consistent with CMS rules, guidelines, and regulations, including, but not limited to, the Annual Notice of Change (ANOC) /Summary of Benefits (SB)/Evidence of Coverage (EOC), Provider Directories, Enrollment and Disenrollment notices, Coverage Denials, ID card, and other standardized and/or mandated notices.
Applicant agrees to accept enrollment elections during valid election periods from all MA eligible Medicare beneficiaries who reside in the MA service area, as provided in Chapter 2 of the MMCM.
Applicant agrees to accept responsibility for accurately determining the eligibility of the beneficiary for enrollment, as described in Chapter 2 of the MMCM.
Applicant agrees to accept responsibility for determining that a valid election period exists, permitting the beneficiary to request enrollment in the MAO’s product, and will accept voluntary disenrollments only during timeframes specified by CMS.
Applicant agrees to collect and transmit data elements specified by CMS for the purposes of enrolling and disenrolling beneficiaries in accordance with the CMS’ Eligibility, Enrollment and Disenrollment Guidance.
Applicant agrees to ensure that enrollee coverage in the plan begins as of the effective date of enrollment in the plan, consistent with the detailed procedures described in the CMS enrollment guidance. Organizations may not delay enrollment or otherwise withhold benefits while waiting for successful (i.e., accepted) transactions to/from MARx.
Applicant agrees to develop, operate and maintain viable systems, processes, and procedures for the timely, accurate, and valid enrollment and disenrollment of beneficiaries in the MAO, consistent with all CMS requirements, guidelines, and regulations.
In the event of contract termination, applicant will notify enrollees of termination and of alternatives for obtaining other MA coverage, as well as Medicare prescription drug coverage, in accordance with Part 422 and Part 423 regulations.
Applicant agrees to establish business processes and communication protocols for the prompt resolution of urgent issues affecting beneficiaries, such as late changes in enrollment or co-pay status, in collaboration with CMS.
Applicant acknowledges that enrollees can make enrollment changes, during election periods for which they are eligible, in the following ways: A) Electing a different MA plan by submitting an enrollment request to that MAO, B) Submitting a request for disenrollment to the MAO in the form and manner prescribed by CMS.
Applicant agrees to perform the following functions upon receipt of an enrollee’s request for voluntary disenrollment: Submit a disenrollment transaction to CMS within timeframes specified by CMS. Provide enrollee with notice to acknowledge disenrollment request in a format specified by CMS. File and retain disenrollment requests for the period specified in CMS instructions, and In cases where lock-in applies, include in the notice a statement explaining that The member remains enrolled until the effective date of disenrollment Until the effective date of disenrollment (except for urgent and/or emergent care) neither the MAO nor CMS will pay for services that have not been provided or arranged for by the MAO prior to voluntary disenrollment.
Applicant will comply with all standards and requirements regarding involuntary disenrollment of an individual initiated by the MAO for any circumstances listed below: Any monthly plan premiums are not paid on a timely basis, subject to the grace period for late payment. Individual has engaged in disruptive behavior. Individual provides fraudulent information on his or her election form or permits abuse of his or her enrollment card.
If the applicant disenrolls an individual for the reasons stated above, applicant agrees to give the individual required written notice(s) of disenrollment with an explanation of why the MAO is planning to disenroll the individual. Notices and reason must: Be provided to the individual before submission of the disenrollment to CMS. Include an explanation of the individual's right to a hearing under the MAO's grievance procedure.
Applicant acknowledges and commits to utilizing HPMS as the principle tool for submitting and receiving formal communications related to MAO performance, enrollee inquiries (CTM), notices and memoranda from CMS staff, routine reporting, and the fulfillment of other functional and regulatory responsibilities and requirements, including, but not limited to, the submission of marketing materials, applications, attestations, bids, contact information, and oversight activities.
On a monthly basis, applicant agrees to accurately and thoroughly process and submit the necessary information to validate enrollment in support of the monthly payment, as provided under 42 CRF 422 subpart G.

15. Working Aged Membership

The purpose of these attestations is to ensure that applicants report all working aged members to CMS, as well as to identify amounts payable, coordinate benefits to enrollees, and identify primary Medicare patients. The following attestations were developed to implement the regulations of 42 CFR 422.108.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: WORKING AGED MEMBERSHIP	YES	NO
Applicant agrees to identify, document, and report to CMS relevant coverage information for working aged, including: Identify payers that are primary to Medicare Identify the amounts payable by those payers Coordinate the applicants benefits or amounts payable with the benefits or amounts payable by the primary payers.

16. Claims

The purpose of these attestations is to ensure that the applicant properly dates and processes all claims, per CMS instructions listed herein. These attestations also provide the applicant with general guidance on how to appropriately notify beneficiaries of claim decisions. The following attestations were developed to implement the regulations of 42 CFR 422.504(c) and 42 CFR 422.520(a).

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS	YES	NO
Applicant agrees to date stamp all claims as they are received, whether in paper form or via electronic submission, in a manner that is acceptable to CMS.
Applicant will ensure that all claims are processed promptly and in accordance with CMS regulations and guidelines.
Applicant agrees to give the beneficiary prompt notice of acceptance or denial of a claim’s payment in a format consistent with the appeals and notice requirements stated in 42 CFR Part 422 Subpart M.
Applicant agrees to comply with all applicable standards and requirements and establish meaningful procedures for the development and processing of all claims, including having an effective system for receiving, controlling, and processing claims actions promptly and correctly.
Applicant agrees to use an automated claims system that demonstrates the ability to accurately and timely pay contracted and non-contracted providers according to CMS requirements.

17. Communications between MAO and CMS

CMS is committed to ensuring clear communications with MAOs. The purpose of this section is to ensure that all applicants engage in effective and timely communications with CMS. Such communications will help improve and support administrative coordination between CMS and MAOs. The following attestations were developed to implement the regulations of 42 CFR 422.504(b).

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: COMMUNICATIONS	YES	NO
Applicant agrees to facilitate the provision of access to and assignment of User IDs and Passwords for CMS systems applications for all key functional, operational, and regulatory staff within the MAO to ensure the timely completion of required transactions within the CMS systems structure, including HPMS, MARx and any other online application with restricted access.
Applicant acknowledges and commits to utilizing HPMS as the principle tool for submitting and receiving formal communications related to MAO performance, enrollee inquiries (CTM), notices and memoranda from CMS staff, routine reporting, and the fulfillment of other functional and regulatory responsibilities and requirements including, but not limited to, the submission of marketing materials, applications, attestations, bids, contact information, and oversight activities.
Applicant agrees to establish connectivity to CMS via the AT&T Medicare Data Communications Network (MDCN) or via the Gentran Filesaver.
Applicant agrees to submit test enrollment and disenrollment transmissions.
Applicant agrees to submit enrollment, disenrollment and change transactions to CMS within 7 calendar days to communicate membership information to CMS each month.
Applicant agrees to reconcile MA data to CMS enrollment/payment reports within 45 days of availability.
Applicant agrees to submit enrollment/payment attestation forms within 45 days of CMS report availability.
Applicant agrees to ensure that enrollee coverage in the plan begins as of the effective date of enrollment in the plan, consistent with the detailed procedures described in the CMS enrollment guidance. Organizations may not delay enrollment or otherwise withhold benefits while waiting for successful (i.e. accepted) transactions to/from MARx.

18. Grievances

CMS is committed to guaranteeing that Medicare beneficiaries have access to, education on, decision making authority for, and are in receipt of quality health care. To ensure that beneficiaries have the ability to express their concerns and that those concerns are acted on promptly, MAOs must have a grievance program structured in compliance with CMS regulations and guidelines. In this capacity, a grievance is defined as any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. Enrollees or their representatives may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration period. In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.

The following attestations were developed to implement the regulations of 42 CFR 422.561and 42 CFR 422.564.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: GRIEVANCES	YES	NO
Applicant agrees to comply with all applicable regulations, standards, guidelines and/or requirements, establishing meaningful processes, procedures, and effectively training the relevant staff and subcontractors (first tier, downstream and related entities), to accept, identify, track, record, resolve, and report enrollee grievances within the timelines established by CMS. An accessible and auditable record of all grievances received on behalf of the MAO, both oral and written, will be maintained to include, at a minimum: the receipt date, mode of submission (i.e. fax, telephone, letter, e-mail, etc.), originator of grievance (person or entity), enrollee affected, subject, final disposition, and date of enrollee notification of the disposition.
Applicant agrees to advise all MA enrollees of the definition of a grievance, their rights, the relevant processes, and the timelines associated with the submission and resolution of grievances to the MAO and its subcontractors (first tier, downstream and related entities) through the provision of information and outreach materials.
Applicant agrees to accept grievances from enrollees at least by telephone and in writing (including fax).
Applicant agrees to inform enrollees of the complaint process that is available to the enrollee under the Quality Improvement Organization (QIO) process.

19. Appeals

CMS recognizes the importance of the appeals process for both MAOs and Medicare beneficiaries. The purpose of this section is to ensure that beneficiaries have the opportunity to submit an appeal. Accordingly, MAOs must have an appeals process structured in compliance with CMS regulations and guidelines. An appeal is defined as any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service, as defined under 422.566(b). These procedures include reconsiderations by the MAO, and if necessary, an independent review entity, hearings before an Administrative Law Judge (ALJ), review by the Medicare Appeals Council (MAC), and judicial review. The following attestations were developed to implement the regulations of 42 CFR 422.561.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: APPEALS	YES	NO
Applicant agrees to adopt policies and procedures for beneficiary organizational determinations, exceptions, and appeals consistent with 42 CFR 422, subpart M.
Applicant agrees to maintain a process for completing reconsiderations that includes a written description of how its organization will provide for standard reconsideration requests and expedited reconsideration requests, where each are applicable, and how its organization will comply with such description. Such policies and procedures will be made available to CMS on request.
Applicant agrees to ensure that the reconsideration policy complies with CMS regulatory timelines for processing standard and expedited reconsideration requests as expeditiously as the enrollee's health condition requires.
Applicant agrees to ensure that the reconsideration policy complies with CMS requirements as to assigning the appropriate person or persons to conduct requested reconsiderations.
Applicant agrees to ensure that the reconsideration policy complies with CMS timeframes for forwarding reconsideration request cases to CMS' independent review entity (IRE) where the applicant affirms an organization determination adverse to the member or as otherwise required under CMS policy.
Applicant agrees to ensure that its reconsideration policy complies with CMS required timelines regarding applicants effectuation through payment, service authorization or service provision in cases where the organization's determinations are reversed in whole or part (by itself, the IRE, or some higher level of appeal) in favor of the member.
Applicant agrees to make its enrollees aware of the organization determination, reconsideration, and appeals process through information provided in the Evidence of Coverage and outreach materials.
Applicant agrees to establish and maintain a process designed to track and address in a timely manner all organization determinations and reconsideration requests, including those transferred to the IRE, an Administrative Law Judge (ALJ) or some higher level of appeal, received both orally and in writing, that includes, at a minimum: Date of receipt Date of any notification Disposition of request Date of disposition
Applicant agrees to make available to CMS, upon CMS request, organization determination and reconsideration records.
Applicant agrees to not restrict the number of reconsideration requests submitted by or on behalf of a member.

20. 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
Applicant complies with all applicable standards, implementation specifications, and requirements in the Standards for Privacy of Individually Identifiable Health Information and Security Standards under 45 CFR Parts 160, 162, and 164.
Applicant agrees to encrypt all hard drives and other electronic storage media, including all removable media, containing electronic protected health information (PHI).
Applicant agrees to have policies addressing the secure handling of portable media that are accessed or used by the organization.
Applicant complies with all applicable standards, implementation specifications, and requirements in the Standard Unique Health Identifier for Health Care Providers under 45 CFR Parts 160 and 162.
Applicant complies with all applicable standards, implementation specifications, operating rules, and requirements in the Standards for Electronic Transactions under 45 CFR Parts 160 and 162.
Applicant agrees to accept the monthly capitation payment consistent with the HIPAA-adopted ASC X12N 820, Payroll Deducted and Other Group Premium Payment for Insurance Products (“820”).
Applicant agrees to submit the Offshore Subcontract Information and Attestation for each offshore subcontractor (first tier, downstream, and related entities) that receive, process, transfer, handle, store, or access Medicare beneficiary PHI by the last Friday in September for the upcoming contract year.
Applicant agrees to not use any part of an enrollee’s Social Security Number (SSN) or Medicare ID Number (i.e., Health Insurance Claim Number) on the enrollee’s identification card.

21. Continuation Area

The purpose of a continuation area is to ensure continuity of care for enrollees who no longer reside in the service area of a plan and who permanently move into the geographic area designated by the MAO as a continuation area. A continuation area is defined as an additional area (outside the service area) within which the MAO offering a local plan furnishes or arranges to furnish services to its continuation-of-enrollment enrollees. Enrollees must reside in a continuation area on a permanent basis and provide documentation that establishes residency, such as a driver’s license or voter registration card. A continuation area does not expand the service area of any MA local plan. The following attestations were developed to implement the regulations of 42 CFR 422.54.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTINUATION AREA	YES	NO	N/A
Applicant agrees to establish a continuation area (outside the service area) within which the MAO offering a local plan furnishes or arranges to furnish services to its enrollees that initially resided in the contract service area.
Applicant agrees to submit marketing materials that will describe the continuation area options.
Applicant agrees to make arrangements with providers for payment of claims for Medicare covered benefits to ensure beneficiary access to services in the continuation area.
Applicant agrees to provide for reasonable cost-sharing for services furnished in the continuation area. An enrollee's cost-sharing liability is limited to the cost-sharing amounts required in the MA local plan's service area (in which the enrollee no longer resides).

22. Part C Application Certification

1. In HPMS, upload a completed and signed Adobe.pdf format copy of the Part C Application Certification Form.

Note: Once the Part C application is complete, applicants seeking to offer a Part D plan must complete the Part D application in HPMS. PFFS and Cost Plan SAE organizations have the option to offer Part D plans. MSAs are not allowed to offer Part D plans.

23. RPPO Essential Hospital

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: RPPO ESSENTIAL HOSPITAL	YES	NO
Applicant is requesting essential hospital designation for non-contracted hospitals. If “Yes”, upload in HPMS a completed CMS Essential Hospital Designation Table and Attestation.

2. In HPMS, upload a completed CMS Essential Hospital Designation Table.

24. Access to Services (PFFS & MSA)

The purpose of these attestations is to provide the applicant with information regarding the offering of the various PFFS models, including a network, partial network, or non-network PFFS model to its members, as applicable. Additionally, these attestations will inform the applicant of the documents and/or information that will need to be uploaded into HPMS. The following attestations were developed to implement the regulations of 42 CFR 422.114(a)(2)(iii).

Please note that, effective with contract year 2016, Section 1862(d) of the SSA, as amended by Section 162(a)(1) of MIPPA, requires those PFFS plans operating in “network areas” to meet the access standards described in section 1852(d)(4)(B) of the Act through contracts with providers. The list of those areas considered “network areas” for purposes of the 2016 application and contracting requirements can be found at: http://www.cms.hhs.gov/PrivateFeeforServicePlans/. CMS will not accept a non-network or partial network application that includes any of the areas identified as “network areas” in the referenced document. Furthermore, applicants wishing to offer both network PFFS products and non-network or partial network PFFS products must do so under separate contracts.  

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: ACCESS TO SERVICES	YES	NO	N/A
Applicant agrees to offer a combination PFFS Model that meets CMS’ access requirements per 42 CFR 422.114(a)(2)(iii). Note: If the applicant has established payment rates that are less than Original Medicare for one or more categories of Medicare covered services under the MA PFFS plan, the applicant must offer a combination PFFS model. *This attestation is not applicable to MSA applicants.
Applicant agrees to offer a network PFFS model only per 42 CFR 422.114(a)(2)(ii). Note: If the applicant has established payment rates that are less than Original Medicare for all Medicare covered services under the MA PFFS plan, then the applicant must offer a network PFFS model. *This attestation is not applicable to MSA applicants.
Applicant agrees to offer a non-network PFFS model only per 42 CFR 422.114(a)(2)(i). *This attestation is not applicable to MSA applicants.
If providing a network or partial network PFFS plan, Applicant has direct contracts and agreements with a sufficient number and range of providers, to meet the access standards described in section 1852(d)(i) of the Act. *This attestation is not applicable to MSA applicants.
If providing a combination network, applicant is providing a direct contracted network for the following Medicare covered services: DROP DOWN BOX WITH THE FOLLOWING SERVICES: • Acute Inpatient Hospital Care • Diagnostic & Therapeutic Radiology (excluding mammograms) • DME/Prosthetic Devices • Home Health Services • Lab Services • Mental Illness – Inpatient Treatment • Mental Illness – Outpatient Treatment • Mammography • Renal Dialysis – Outpatient • SNF Services • Surgical Services (outpatient or ambulatory) • Therapy – Outpatient Occupational/Physical • Therapy – Outpatient Speech • Transplants (Heart, Heart and Lung, Intestinal, Kidney, Liver, Lung, Pancreas) • Other Note: If applicant selects "Other", upload in HPMS a thorough description of proposed services, including rationale for providing a contract network for the proposed service. If applicant proposes to furnish certain categories of service through a contracted network, upload in HPMS a narrative description of the proposed network. Please ensure that the categories are clearly defined in the narrative description. *This attestation is not applicable to MSA applicants.
Applicant agrees to post the organization's "Terms and Conditions of Payment" on its website, which describes to members and providers the plan payment rates (including member cost sharing) and provider billing procedures. Note: applicant can use CMS model terms and conditions of payment guidance. *This attestation is not applicable to MSA applicants.
Applicant agrees to provide information to its members and providers explaining the provider deeming process and the payment mechanisms for providers. *This attestation is not applicable to MSA applicants.

NOTE: PFFS applicants must select the combination PFFS model, the network model or the non-network model (Attestations #1-3) as appropriate for each type of contract (and application) they seek. A single contract cannot encompass more than one of these models.

2. In HPMS, upload a description of Proposed Services for combination networks, if applicant selects "Other" for question 5. If applicant proposes to furnish certain categories of service through a contracted network, please ensure that the categories are clearly defined in the narrative description. This upload is required for selected PFFS applicants.

2. In HPMS, upload a description of how the applicant will follow CMS’s national coverage decisions and written decisions of carriers and intermediaries (LMRP) throughout the United States (Refer to 42 CFR 422.101 (b)). This upload is required for PFFS and MSA applicants.

2. In HPMS, upload a description of how the applicants policies ensure that health services are provided in a culturally competent manner to enrollees of different backgrounds. This upload is required for PFFS and MSA applicants.

25. Claims Processing (PFFS & MSA)

The purpose of these attestations is to verify that the applicant uses a validated claims system, properly implements the Reimbursement Grid and pays all providers according to the PFFS plan's terms and conditions of payment. Additionally, upon request, the applicant will submit to CMS its complete and thorough Provider Dispute Resolution Policies and Procedures (P&Ps), bi-weekly reports detailing complaints, and/or bi-weekly reports detailing appeals and/or claims. The following attestations were developed to implement the regulations of 42 CFR 422.216.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CLAIMS PROCESSING	YES	NO
Applicant agrees to use a claims system that was previously tested and demonstrates the ability to accurately and timely pay Medicare FFS payments.
If using a claims system that was not previously validated, Applicant agrees to provide documentation upon request.
Applicant has in place the necessary operational claims systems, staffing, processes, functions, etc. to properly institute the Reimbursement Grid and pay all providers according to the PFFS plan’s terms and conditions of payment. *This attestation is not applicable to MSA Plans.
Applicant agrees that upon request, it will submit its complete and thorough Provider Dispute Resolution Policies and Procedures (P&Ps) to address any written or verbal provider dispute/complaints, particularly regarding the amount reimbursed. The availability of these P&Ps must be disclosed to providers. The applicant must submit information on how it has integrated the P&Ps into all staff training - particularly in Provider Relations, Customer Service and Appeals/Grievances.
Applicant agrees that upon request, it will submit a biweekly report to the CMS RO Account Manager that outlines all provider complaints (verbal and written), particularly where providers or beneficiaries question the amount paid for six months following the receipt of the first claim. This report will outline the investigation and the resolution including the completion of a CMS designed worksheet.
Applicant agrees that upon request, it will submit a biweekly report to the CMS RO Account Manager that outlines all beneficiary appeals and/or complaints (verbal and written) related to claims for the six months following the receipt of the first claim. This report will outline the investigation and the resolution including the completion of CMS designed worksheet.

26. Payment Provisions

This section may be applicable to PFFS & MSA Plans

The purpose of these attestations is to ensure that the applicant has an appropriate system in place to properly pay providers and to ensure that enrollees are not being overcharged. Additionally, it instructs applicants to upload a Reimbursement Grid in HPMS. The following attestations were developed to implement the regulations of 42 CFR 422.216(c).

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PAYMENT PROVISIONS	YES	NO	N/A
PFFS Plans -- Applicant has a system in place that allows the applicant to correctly pay providers who furnish services to its members the correct payment rate according to the PFFS plan's terms and conditions of payment (e.g., if the PFFS plan meets CMS' access requirements by paying providers at Original Medicare payment rates, then it will have a system in place to correctly pay at those rates throughout the United States). *This attestation is not applicable to MSA applicants.
The applicant has a system in place to ensure members are not charged more in cost sharing or balance billing than the amounts specified in the PFFS plan's terms and conditions of payment. [Refer to 42 CFR 422.216(c)]. *This attestation is not applicable to MSA applicants
Applicant agrees that information in the Payment Reimbursement Grid is true and accurate. (PFFS and MSA applicants)
Applicant agrees to ensure that members are not charged more than the Medicare-allowed charge (up to the limiting charge for non-Medicare participating providers) when they receive medical services.
Applicant has a system in place to timely furnish an advance determination of coverage upon a verbal or written request by a member or provider.
The applicant has a system in place to ensure members are not charged after the deductible has been met. [Refer to 42 CFR 422.103(c)]. *This attestation is not applicable to PFFS applicants.
Applicant agrees to allow providers to balance bill the beneficiary up to allowed amount. Note: This only applies to applicants that allow balance billing.

2. In HPMS, upload a completed Payment Reimbursement grid.

Note: Organization may use any format for the Payment Reimbursement grid that best outlines the organization’s rates. There is no CMS-prescribed format.

27. General Administration/Management

This section is applicable to MSA applicants

The purpose of these attestations is to ensure that the applicant is offering Medical Savings Accounts (MSA) plans that follow requirements set forth in law, regulation and CMS instructions. The applicant may establish a relationship with a banking partner and have a system in place to receive Medicare deposits to MSA plan enrollee accounts. The following sections of 42 CFR 422 contain provisions that are specific to Medical Savings Accounts : 422.2, 422.4(a) and (c), 422.56, 422.62(d), 422.100(b)(2), 422.102(b), 422.103, 422.104, 422.111(a), 422.152, 422.252, 422.254(e), 422.256(e), 422.262(b)(2), 422.270(a)(1), 422.304(c)(2), and lastly, 422.314.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: MEDICAL SAVINGS ACCOUNTS (MSA)	YES	NO
Applicant is offering network MSA plans that follow the CCP network model.
Applicant is offering network MSA plans that follow the PFFS network model.
Applicant currently operates a commercial Health Savings Account (HSA) plan or other type of commercial tax-favored health plan or an MA Medical Savings Account (MSA) plan.
Applicant agrees to serve as the MA MSA Trustee or Custodian for receiving Medicare deposits to MSA plan enrollee accounts.
Applicant agrees to establish a relationship with a banking partner that meets the Internal Revenue Service (IRS) requirements (as a bank, insurance company or other entity) as set out in Treasury Reg. Secs. 1.408-2(e)(2) through (e)(5). If “Yes”, upload the banking contract in HPMS.
Applicant agrees to establish policies and procedures with its banking partner that include the services provided by the banking partner, including how members access funds, how spending is tracked and applied to the deductible, and how claims are processed.

2. In HPMS, upload the banking contract for review by CMS and the applicant, if applicant answered “Yes” to question 5 above, to ensure that ALL CMS direct and/or any delegated contracting requirements are included in the contract.

3. In HPMS, upload a description of how the applicant will track enrollee usage of information provided on the cost and quality of providers. Be sure to include how the applicant intends to track use of health services between those enrollees who utilize transparency information and those who do not.

4. In HPMS, upload a description of how the applicant will recover current-year deposit amounts for members who are disenrolled from the plan before the end of the calendar year.

3. Document Upload Templates

1. History/Structure/Organizational Charts

Note: CMS REQUESTS THAT YOU LIMIT THIS DOCUMENT TO EIGHT (8) PAGES.

Please Check:

_____New to the MA program (initial application)

_____Cost Plan SAE Application

SECTION 1: All applicants (new and existing) must complete this section.

1. Please give a brief summary of applicants history.

1. Structure:

2. Ownership:

2. Attach a diagram of applicants ownership structure.

3. Attach a diagram of the applicants relation to its subsidiaries, as well as its business affiliations.

SECTION II: Applicants that are new to the MA Program must complete this section.

1. Please provide the date of the company’s last financial audit.

2. What were the results of that audit?

3. Briefly describe the financial status of the applicants company.

4. Briefly explain the applicants marketing philosophy.

5. Who in the applicants organization can appoint and remove the executive manager?

6. Please submit a brief description and/or a flow chart of the applicants claims processing systems and operations.

7. Please submit a brief description and/or flow chart of the applicants grievances process.

8. Please provide a brief description and flow chart of the applicants appeals process.

9. If applicable, please provide the name of the claims systems that applicant tested to demonstrate the systems’ ability to pay Medicare FFS payments.

2. Minimum Enrollment Waiver Request Upload Document

Minimum Enrollment Waiver Request Upload Document

Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.

2015 Minimum Enrollment Waiver Request Upload Document

Applicant’s Contract Name (as provided in HPMS):

Enter contract name here.

Applicant’s CMS Contract Number:

Enter contract number here.

1. a) Does the contract applicant (organization) have previous experience in managing and providing health care services under a risk-based payment arrangement to at least as many individuals as the applicable minimum enrollment for the entity as described in 42 CFR §422.514? (yes/no).

b) If response in 1(a) is yes, please describe the extent of this experience.

Enter your response to #1 here. If more space is required please attach additional sheets.

2. a) Does the contract applicant’s parent organization have previous experience in managing and providing health care services under a risk-based payment arrangement to at least as many individuals as the applicable minimum enrollment for the entity as described in 42 CFR §422.514? (yes/no).

b) If response in 2(a) is yes, please describe the extent of this experience.

Enter your response to #2 here. If more space is required please attach additional sheets.

3. a) Does the contract applicant’s management and providers have previous experience in managing and providing health care services under a risk-based payment arrangement to at least as many individuals as the applicable minimum enrollment for the entity as described in 42 CFR §422.514? (yes/no).

b) If response in 3(a) is yes, please describe the extent of this experience.

Enter your response to #3 here. If more space is required please attach additional sheets.

4. a) Does the applicant have stop-loss insurance? (yes/no)

b) If response in 4(a) is yes, please provide evidence of this stop-loss insurance.

Enter your response to #4 here. If more space is required please attach additional sheets.

5. Please describe how your organization is able to establish a marketing and enrollment process that allows your organization to meet the applicable minimum enrollment requirements specified in 42 CFR §422.514.

Enter your response to #5 here. If more space is required please attach additional sheets.

3. CMS State Certification Form

INSTRUCTIONS

(MA State Certification Form)

General:

This form is required to be submitted with all MA applications. The MA applicant is required to complete the items above the line (items 1 - 4), then forward the document to the appropriate State Agency Official who should complete those items below the line (items 5-8). After completion, the State Agency Official should return this document to the applicant organization for submission to CMS as part of its application for a MA contract.

The questions provided must be answered completely. If additional space is needed to respond to the questions, please add pages as necessary. Provide additional information whenever you believe further explanation will clarify the response.

The MA State Certification Form demonstrates to CMS that the MA contract being sought by the applicant organization is within the scope of the license granted by the appropriate State regulatory agency, that the organization meets state solvency requirements and that it is authorized to bear risk. A determination on the organization’s MA application will be based upon the organization’s entire application that was submitted to CMS, including documentation of appropriate licensure.

Items 1 - 4 (to be completed by the applicant):

1. List the name, d/b/a (if applicable) and complete address of the organization that is seeking to enter into the MA contract with CMS.

2. Indicate the type of license (if any) the applicant organization currently holds in the State where the applicant organization is applying to offer an MA contract.

3. Specify the type of MA contract the applicant organization is seeking to enter into with CMS.

4. Enter the National Association of Insurance Commissioners (NAIC) number if there is one.

New Federal Preemption Authority – The Medicare Modernization Act amended section 1856(b)(3) of the SSA to significantly broaden the scope of Federal preemption of State laws governing plans serving Medicare beneficiaries. Current law provides that the provisions of Title XVIII of the SSA supersede State laws or regulations, other than laws relating to licensure or plan solvency, with respect to MA plans.

Items 5 - 8 (to be completed by State Official):

5. List the reviewer’s pertinent information in the event CMS needs to communicate with the individual conducting the review at the State level.

6. List the requested information regarding other State departments/agencies required to review requests for licensure.

7. A. Circle where appropriate to indicate whether the applicant meets State financial solvency requirements.

B. Indicate State Agency or Division, including contact name and complete address, that is responsible for assessing whether the applicant meets State financial solvency requirements.

8. A. Circle where appropriate to indicate whether the applicant meets State licensure requirements.

B. Indicate State Agency or Division, including contact name and complete address, that is responsible for assessing whether the applicant meets State licensing requirements.

MEDICARE ADVANTAGE (MA)

STATE CERTIFICATION REQUEST

MA applicants should complete items 1-4.

1. MA applicant Information (Organization that has applied for MA contract(s)):

Name _______________________________________________________________

D/B/A (if applicable) ___________________________________________________

Address _____________________________________________________________

City/State/Zip ________________________________________________________

2. Type of State license or Certificate of Authority currently held by referenced applicant: (Circle more than one if entity holds multiple licenses)

● HMO ● PSO ● PPO ● Indemnity ● Other ________

Comments:

3. Type of MA application filed by the applicant with the Centers for Medicare & Medicaid Services (CMS): (Circle all that are appropriate)

● HMO ● PPO ● MSA ● PFFS ● Religious/Fraternal

Requested Service Area: _______________________________________________________________

4. National Association of Insurance Commissioners (NAIC) number: ____________

I certify that ____________________’s application to CMS is for the type of MA plan(s) and the service area(s) indicated above in questions 1-3.

______________________________

MAO

_________________ ______________________________

Date CEO/CFO Signature

_____________________________

Title

(An appropriate State official must complete items 5-8)

Please note that under section 1856(b)(3) of the SSA and 42 CFR 422.402, other than laws related to State licensure or solvency requirements, the provisions of title XVIII of the SSA preempt State laws with respect to MA plans.

5. State official reviewing MA State Certification Request:

Reviewer’s Name _______________________________________________________________

State Oversight/Compliance Officer _______________________________________________________________

Agency Name _______________________________________________________________

Address _______________________________________________________________

Address _______________________________________________________________

City/State _______________________________________________________________

Telephone ________________________________________________________________

E-Mail Address _______________________________________________________________

5. Name of other State agencies (if any) whose approval is required for licensure:

Agency______________________________________________

Contact Person________________________________________

Address______________________________________________

City/State____________________________________________

Telephone____________________________________________

E-Mail Address _______________________________________

5. Financial Solvency:

Does the applicant organization named in item 1 above meet State financial solvency requirements? (Please circle the correct response)

● Yes ● No

Please indicate which State Agency or Division is responsible for assessing whether the named applicant organization meets State financial solvency requirements.

_______________________________________________________________

8. State Licensure:

Does the applicant organization named in item 1 above meet State Licensure requirements? (Please circle the correct response)

● Yes ● No

Please indicate which State Agency or Division is responsible for assessing whether this organization meets State licensure requirements.

______________________________________________________________

State Certification

I hereby certify to the Centers for Medicare & Medicaid Services (CMS) that the above organization (doing business as (d/b/a) _________________________) is:

(Check one)

________ licensed in the State of ___________ as a risk bearing entity, or

________ authorized to operate as a risk bearing entity in the State of ________________

And

(Check one)

________ is in compliance with State solvency requirements, or

________ State solvency requirement not applicable [please explain below].

By signing the certification, the State of __________ is certifying that the organization is licensed and/or that the organization is authorized to bear the risk associated with the MA product circled in item 3 above. The State is not being asked to verify plan eligibility for the Medicare managed care products(s) or CMS contract type(s) requested by the organization, but merely to certify to the requested information based on the representation by the organization named above.

____________________________________

Agency

_________________ ____________________________________

Date Signature

______________________________ Title

4. Part C Application Certification Form

I, , attest to the following:

(NAME & TITLE)

1. I have read the contents of the completed application and the information contained herein is true, correct, and complete. If I become aware that any information in this application is not true, correct, or complete, I agree to notify the Centers for Medicare & Medicaid Services (CMS) immediately and in writing.

1. I authorize CMS to verify the information contained herein. I agree to notify CMS in writing of any changes that may jeopardize my ability to meet the qualifications stated in this application prior to such change or within 30 days of the effective date of such change. I understand that such a change may result in termination of the approval.

2. I agree that if my organization meets the minimum qualifications, is Medicare-approved, and my organization enters into a Part C contract with CMS, I will abide by the requirements contained in Section 3 of this Application and provide the services outlined in my application.

3. I agree that CMS may inspect any and all information necessary, including inspecting of the premises of the applicants organization or plan to ensure compliance with stated Federal requirements, including specific provisions for which I have attested. I further agree to immediately notify CMS if, despite these attestations, I become aware of circumstances that preclude full compliance by January 1 of the upcoming contract year with the requirements stated here in this application as well as in Part 422 of 42 CFR of the regulation.

4. I understand that in accordance with 18 U.S.C. §1001, any omission, misrepresentation or falsification of any information contained in this application or contained in any communication supplying information to CMS to complete or clarify this application may be punishable by criminal, civil, or other administrative actions including revocation of approval, fines, and/or imprisonment under Federal law.

5. I further certify that I am an authorized representative, officer, chief executive officer, or general partner of the business organization that is applying for qualification to enter into a Part C contract with CMS.

6. I acknowledge that I am aware that there is operational policy guidance, including the forthcoming Call Letter, relevant to this application that is posted on the CMS website and that it is continually updated. Organizations submitting an application in response to this solicitation acknowledge that they will comply with such guidance should they be approved for a Part C contract.

Authorized Representative Name (printed) Title

Authorized Representative Signature Date (MM/DD/YYYY)

5. RPPO State Licensure Table

Complete a separate table for each MA Region which the applicant proposes to serve pursuant to this application. Please make copies as necessary.

Entity Name: ____________________________

MA Region: _____________________________

State (Two Letter Abbrev.)	Is Applicant Licensed in State? Yes or No	If No, Give Date Application was Filed with State	Type of License Held or Requested	Does State have Restricted Reserve Requirements (or Legal Equivalent)? If Yes, Give Amount	State Regulator’s Name, Address Phone #

6. RPPO State Licensure Attestation

By signing this attestation, I agree that the applicant has applied to be licensed, in each state of its regional service area(s) in which it is not already licensed, sufficient to authorize applicant to operate as a risk bearing entity that may offer health benefits, including an MA Regional Preferred Provider Organization (RPPO) product.

I understand that, in order to offer an MA RPPO plan, section 1858(d) of the SSA, as added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173), requires an entity to be licensed in at least one state in each of the RPPO Regions it seeks to cover in order to receive a temporary licensure waiver. This temporary waiver is to allow for the timely processing, as determined by CMS, of licensure applications for other states within the requested RPPO Region.

I understand that my organization will be required to provide documentary evidence of its filing or licensure status for each state of its regional service area(s) consistent with this attestation. I further understand that CMS may contact the relevant state regulators to confirm the information provided in this attestation as well as the status of applicants licensure request(s).

I further agree to immediately notify CMS if, despite this attestation, I become aware of circumstances that indicate noncompliance with the requirements indicated above.

Name of Organization: ____________________________________________________

Printed Name of CEO: ____________________________________________________

Signature: ____________________________________________________

7. RPPO Essential Hospital Designation 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.

Hospital name and address (including county)	Contact person and phone	Hospital NPI Number	Hospital Type/Provider ID Number	Method by which offer was communicated	Date(s) offer refused/how refused	Why hospital is needed to meet RPPO’s previously submitted access standards, including distance from named hospital to next closest Medicare participating contracted hospital
Happy Care Medical Center 123 Happy Street, City, State 12345 ABC County	Any Body, CFO (123) 456-7890		Acute Care/ 210076	2 Letter Offers followed by 2 phone calls	Letter dated 8/02/05. Confirmed by phone call with CFO	Nearest Medicare participating inpatient facility with which applicant contracts is in downtown Wines Place, AZ – 35 or more miles away from beneficiaries in ABC County. Applicants hospital access standard is 98% of beneficiaries in ABC County and northern half of DEF County have access to inpatient facility within 30 miles drive.

8. RPPO Essential Hospital Attestation

RPPO Attestation Regarding Designation of “Essential” Hospitals

Applicant Organization named below (the Organization) attests that it made a good faith effort consistent with Section 1858(h) of the SSA and 42 CFR 422.112(c)(3), to contract with each hospital identified by the Organization in the attached chart at rates no less than current Medicare inpatient fee-for-service amounts and that, in each case, the hospital refused to enter into a contract with the Organization.

CMS is authorized to inspect any and all books or records necessary to substantiate the information in this attestation and the corresponding designation requests.

The Organization agrees to notify CMS immediately upon becoming aware of any occurrence or circumstance that would make this attestation inaccurate with respect to any of the designated hospitals. I possess the requisite authority to execute this attestation on behalf of the Organization.

Name of Organization: ______________________________________________

Printed Name of CEO: ______________________________________________

Signature:_________________________________________________________

Medicare Advantage RPPO Application/Contract Number(s):

R#_____ ______ ______ ______ ______ ______ ______ ______ ______ ______

Note: This attestation form must be signed by any organization that seeks to designate one or more hospitals as “essential.”

9. Crosswalk for Part C Quality Improvement (QI) Program

   Crosswalk for Part C QI Program Directions: The purpose of the Crosswalk for Part C QI Program is to ensure that the applicant has a QI Program that is ready for implementation.
   Compliance Plan Element			Reference 42 CFR	Document Page Number
   SECTION I: QI Program For All Plan Types
   Chronic Care Improvement Program that includes the following components:			422.1529(a)(1) 422.152(c)	NA
   	Methods for identifying MA enrollees with multiple or sufficiently severe chronic conditions that would benefit from participating in a chronic care improvement program.
   	Mechanisms for monitoring MA enrollees that are participating in the chronic care improvement program.
   Narrative about quality improvement projects (QIPs) that can be expected to have a beneficial effect on health outcomes and enrollee satisfaction, and include the following components:			422.152(a)(2) 422.152(d)	NA
   	Focus on significant aspects of clinical care and non-clinical services that includes the following:
   		Measurement of performance
   		System interventions, including the establishment or alteration of practice guidelines
   		Improving performance
   		Systematic and periodic follow-up on the effect of the interventions
   	Assessing performance under the plan using quality indicators that are:
   		Objective, clearly and unambiguously defined, and based on current clinical knowledge or health services research
   		Capable of measuring outcomes such as changes in health status, functional status and enrollee satisfaction, or valid proxies of those outcomes
   	Performance assessment on the selected indicators must be based on systematic ongoing collection and analysis of valid and reliable data.
   	Interventions must achieve demonstrable improvement.
   	The organization must report the status and results of each project to CMS as requested.
   Maintain health information system that collects, analyzes and integrates the data necessary to implement the QI Program.			422.152(f)(1)(i)
   Mechanism to ensure that all information received from the providers of services is reliable, complete and available to CMS.			422.152(f)(1)(ii-iii)
   A process for formal evaluation (at least annually) of the impact and effectiveness of the QI Program.			422.152(f)(2)
   Correction of all problems that come to its attention through internal surveillance, complaints, or other mechanisms.			422.152(f)(3)
   SECTION II: For HMOs and Local PPO (licensed or organized under state law as an HMO) (excluding RPPOs)
   Mechanism that encourages its providers to participate in CMS and HHS QI initiatives.			422.152(a)(3)
   Written policies and procedures that reflect current standards of medical practice.			422.152(b)(1)
   Mechanism to detect both underutilization and overutilization of services.			422.152 (b)(2)
   Measurement and reporting of performance must include the following components:			422.152 (b)(3)
   	Use the measurement tools required by CMS and report performance.
   	Make available to CMS information on quality and outcomes measures that will enable beneficiaries to compare health coverage options and select among them.
   SECTION III: For Regional PPO and Local PPOs (that are not licensed or organized under state law as an HMO)
   Use the measurement tools required by CMS and report performance.			422.152 (e)(2)(i)
   Evaluate the continuity and coordination of care furnished to enrollees.			422.152 (e)(2)(ii)
   If using written protocols for utilization review, protocols must be based on current standards of medical practice and have a mechanism to evaluate utilization of services and to inform enrollees and providers of services of the evaluation results.			422.152(e)(2)(iii)(B)

10. Crosswalk to Part C Compliance Plan

Crosswalk for Part C Compliance Plan
Compliance Plan Element		Reference 42 CFR	Document Page Number
Written policies, procedures, and standards of conduct that must include the following seven components:		422.503(b)(4)(vi)(A)	NA
	Articulate the organization’s commitment to comply with all applicable Federal and State standards.
	Describe compliance expectations as embodied in the standards of conduct.
	Implement the operation of the compliance program.
	Provide guidance to employees and others on dealing with potential compliance issues.
	Identify how to communicate compliance issues to appropriate compliance personnel.
	Describe how potential compliance issues are investigated and resolved by the organization.
	Include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues, conducting self-evaluations, audits and remedial actions, and reporting to appropriate officials.
Designation of a compliance officer and a compliance committee that are accountable to senior management and include the following three components:		422.503(b)(4)(vi)(B)	NA
	The compliance officer, vested with the day-to-day operations of the compliance program, must be an employee of the MAO, parent organization or corporate affiliate. The compliance officer may not be an employee of the MAO’s first tier, downstream or related entity.
	The compliance officer and the compliance committee must periodically report directly to the governing body of the MAO on the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program.
	The governing body of the MAO must be knowledgeable about the content and operation of the compliance program and must exercise reasonable oversight with respect to the implementation and effectiveness of the compliance programs.
Effective training and education that must include the following two components:		422.503(b)(4)(vi)(C)	NA
	Implementing an effective training and education between the compliance officer and organization employees, the MAO’s chief executive or other senior administrator, managers and governing body members, and the MAO’s first tier, downstream, and related entities. Such training and education must occur annually at a minimum and must be made a part of the orientation for a new employee, new first tier, downstream and related entities, and new appointment to a chief executive, manager, or governing body member.
	First tier, downstream, and related entities who have met the fraud, waste, and abuse certification requirements through enrollment into the Medicare program are deemed to have met the training and educational requirements for fraud, waste, and abuse.
Establishment and implementation of effective lines of communication, ensuring confidentiality, between the compliance officer, members of the compliance committee, the MAO’s employees, managers and governing body, and the MAO’s first tier, downstream, and related entities. Such lines of communication must be accessible to all and allow compliance issues to be reported, including a method for anonymous and confidential good faith reporting of potential compliance issues as they are identified.		422.503(b)(4)(vi)(D)
Well-publicized disciplinary standards that are enforced and include the following three policies:		422.503(b)(4)(vi)(E)
	Articulate expectations for reporting compliance issues and assist in their resolution.
	Identify noncompliance or unethical behavior.
	Provide for timely, consistent, and effective enforcement of the standards when noncompliance or unethical behavior is determined.
Establishment and implementation of an effective system for routine monitoring and identification of compliance risks. The system should include internal monitoring and audits and, as appropriate, external audits, to evaluate the MAO, including first tier entities’ compliance with CMS requirements and the overall effectiveness of the compliance program.		422.503(b)(4)(vi)(F)
Establishment and implementation of procedures and a system for promptly responding to compliance issues as they are raised, investigating potential compliance self-evaluations and audits, correcting such problems promptly and thoroughly to reduce the potential for recurrence, and ensure ongoing compliance with CMS requirements. The procedures must include the following components:		422.503(b)(4)(vi)(G)
	If the MAO discovers evidence of misconduct related to payment or delivery of items or services under the contract, it must conduct a timely, reasonable inquiry into that conduct.
	The MAO must conduct appropriate corrective actions (for example, recoupment of overpayments, disciplinary actions against responsible employees) in response to the potential violation referenced in paragraph T.
	The MAO should have procedures to voluntarily self-report potential fraud or misconduct related to the MA program to CMS or its designee.

11. Partial County Justification

Instructions: MA applicants requesting service areas that include one or more partial counties must upload a completed Partial County Justification with the MA Application.

Complete and upload a Partial County Justification form for each partial county in your proposed service area. This form is appropriate for organizations (1) entering into a new partial county or (2) expanding a current partial county by one or more zip codes when the resulting service area will continue to be a partial county. In this scenario, the Justification pertains to the proposed zip codes versus the zip codes already approved by CMS.

MA applicants expanding from a partial county to a full county do NOT need to submit a Partial County Justification.

Beginning with the CY2016 applications, HPMS will automatically assess the contracted provider and facility networks against the CMS criteria. If the ACC report shows that a provider or facility fails the network criteria, the applicant must submit an Exception Request using the same process available to full-county applicants.

NOTE: CMS requests that you limit this document to 20 pages.

SECTION I: Partial County Explanation

Using just a few sentences, briefly describe why you are proposing a partial county.

SECTION II: Partial County Requirements

The Medicare Managed Care Manual Chapter 4, Section 150.3 provides guidance on partial county requirements. The following questions pertain to those requirements; refer to Section 150.3 when responding to them.

Explain how and submit documentation to show that the partial county meets all three of the following criteria:

1. Necessary – Check the option(s) that applies to your organization, and provide documentation to support your selection(s):

• You cannot establish a provider network to make health care services available and accessible to beneficiaries residing in the excluded portion of the county.

• You cannot establish economically viable contracts with sufficient providers to serve the entire county.

Describe the evidence that you are providing to substantiate the above statement(s) and (if applicable) attach it to this form:

2. Non-discriminatory – You must be able to substantiate both of the following statements:

• The racial and economic composition of the population in the portion of the county you are proposing is comparable to the excluded portion of the county.

Using U.S. census data (or data from another comparable source), compare the racial and economic composition of the included and excluded portions of the proposed county service area.

• The anticipated health care costs of the portion of the county you are proposing to serve is similar to the area of the county that will be excluded from the service area.

Describe the evidence that you are providing to substantiate the above statement and (if applicable) attach it to this form:

3. In the best interest of beneficiaries – The partial county must be in the best interest of the beneficiaries who are in the pending service area.

Describe the evidence that you are providing to substantiate the above statement and (if applicable) attach it to this form:

SECTION III: Geography

1. Describe the geographic areas for the county, both inside and outside the proposed service area, including the major population centers, transportation arteries, significant topographic features (e.g., lakes, mountain ranges, etc.), and any other geographic factors that affected your service area designation.

3. APPENDIX I: Solicitations for Special Needs Plan (SNP) Proposals

SNP Proposal Instructions

Initial (new) SNP

An initial applicant, seeking to offer a SNP must submit a MA-PD application in conjunction with the SNP Proposal.

An applicant, including an existing MA Organization, offering a new SNP must submit their SNP proposal by completing HPMS SNP Proposal template and submitting all completed upload documents per HPMS User Guide instructions. A SNP proposal must be completed for each SNP type to be offered by the MAO.

A SNP can only be offered in an MA-approved service area.  If the applicant has applied for a new MA service area, approval of the new SNP or SNP SAE is contingent upon approval of the new or expanded MA service area.  If the MA service area is not approved due to unresolved deficiencies, the new SNP or SNP SAE Proposal will not be approved.

All applicants requesting to offer a dual-eligible SNP must have a State Medicaid Agency contract or be in negotiation with the State Medicaid Agency toward that goal. A dual-eligible SNP must have a State Medicaid Agency contract in place prior to the beginning of the 2016 contract year and the contract must overlap the entire CMS 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. Other associated MA and Part D applications must also be completed and submitted. Applicants must read HPMS memos and visit the CMS web site periodically to stay informed about new or revised guidance documents.

SNP Service Area Expansion (SAE)

An MA organization currently offering a SNP that wants to expand the service area of this SNP must adhere to the same requirements for submission of an initial SNP proposal, that is to say they must complete an HPMS SNP Proposal and all completed upload documents per HPMS User Guide instructions. The service area of the proposed SNP cannot exceed the existing or pending service area for the MA contract.

Renewal SNPs that are Not Expanding their Service Area:

An MA organization currently offering a SNP that requires re-approval under the National Committee for Quality Assurance (NCQA) SNP Approval process should only submit its Model of Care written narrative and Model of Care Matrix Upload Document and will not be required to submit any other portion of the MA application or SNP proposal, unless specifically noted (e.g., in the instructions for submission of contracts with State Medicaid Agencies). Any SNP that received a two or three year approval will not be required to submit any other portion of the MA application or SNP proposal unless specifically noted (e.g., to meet the requirement for contracting with a State Medicaid Agency). (Note: The Affordable Care Act amended section 1859(f) of the Social Security Act to require that all SNPs be approved by NCQA starting January 1, 2012, and subsequent years. 42 C.F.R. §§ 422.4(a) (iv), 422.101(f), and 422.152(g) specify that the NCQA approval process be based on evaluation and approval of the model of care (MOC), as per CMS guidance.

6. D-SNP State Medicaid Agency(ies) Contract(s)

Attestation	Response
State Medicaid Agency Contracts
1. Applicant either: (1) has an existing, executed contract(s) with the State Medicaid Agency in the state(s) in which the applicant seeks to operate for the MA application year; or (2) does not have an executed State Medicaid Agency Contract, but has contacted the requisite State Medicaid Agency, initiated contract negotiations and will have a signed contract(s) for the MA application year by July 1, 2015. Note: Applicants for dual-eligible SNPs (initial, existing, and existing/expanding) must have a signed State Medicaid Agency(ies) contract by the CMS specified deadline. A current evergreen, multi year, or future contract must be uploaded each application cycle or year.	Yes/No
Applicant wishes the contract with the State Medicaid Agency(ies) be reviewed to determine if it qualifies as a fully integrated dual eligible SNP (FIDE).	Yes/No If yes, Upload the completed FIDE SNP Contract Matrix with your State Medicaid Agency Contract before July 1, 2015.
3. If the applicant attested to having an existing, executed contract(s) with the State Medicaid Agency in the state(s) in which the applicant seeks to operate for the MA application year, upload a copy of ALL executed State Medicaid Agency Contract(s).	Upload executed contracts for each State Medicaid Agency.
4. If the applicant attested to having an existing, executed contract(s) with the State Medicaid Agency in the state(s) in which the applicant seeks to operate for the MA application year, also upload the D-SNP State Medicaid Agency Contract Matrix Upload Document.	Upload D-SNP State Medicaid Agency Contract Matrix Upload Document

9. I-SNP Attestations

Attestation		Response
I-SNP Individuals Residing ONLY in Institutions
1. Applicant will only enroll institutionalized individuals residing in a long term care facility under contract with or owned by the organization offering the SNP.		Yes/No
2. If applicant answered "Yes" to statement #1, download the I-SNP Individuals Residing Only in Institutions Upload Document, fully complete it, and upload the completed document.		I-SNP Individuals Residing Only in Institutions Upload Document
Attestation		Response
I-SNP Individuals Residing ONLY in the Community
1. Applicant will enroll individuals who are institutional equivalents residing in the community.		Yes/No
2. If applicant answered "Yes" to statement #1, download the I-SNP Residing Only in the Community Upload Document, fully complete it, and upload the completed document.		I-SNP Residing Only in the Community Upload Document
If the applicant answered “Yes” to statement #1, upload a copy of the respective State’s level of care (LOC) assessment tool to determine eligibility for each institutional equivalent beneficiary. NOTE: The applicant must use the respective State (LOC) assessment tool to determine eligibility for institutional equivalent individuals living in the community.		Copy of the respective State’s level of care (LOC) assessment tool to determine eligibility for each institutional equivalent beneficiary
Attestation			Response
I-SNP Individuals Residing in BOTH Institutions and the Community
1. Applicant will enroll individuals who are both institutionalized and institutional equivalents residing in the community.	Yes/No
2. If the applicant answered “Yes” to statement #1, download the I-SNP Individuals Residing in Both Institutions and the Community Upload Document, fully complete it, and upload the completed document.	I-SNP Individuals Residing in Both Institutions and the Community Upload Document
3. If the applicant answered “Yes” to statement #1, upload a copy of the respective State’s level of care (LOC) assessment tool to determine eligibility for each institutional equivalent beneficiary. NOTE: The applicant must use the respective State (LOC) assessment tool to determine eligibility for institutional equivalent individuals living in the community.	Copy of the respective State’s level of care (LOC) assessment tool to determine eligibility for each institutional equivalent beneficiary.

10. C-SNP, D-SNP and I-SNP ESRD Waiver Request

Attestation	Response
ESRD Waiver Requests
1. Applicant is applying to offer a SNP targeting individuals having ESRD.	Yes/No
2. If applicant answered "Yes" to statement #1, download the SNP ESRD Waiver Request Upload Document, fully complete it, and upload the completed document.	Upload ESRD Upload Document.

11. Model of Care Attestations

Attestation	Response
Written Model of Care
1. Applicant has submitted a written description of its Model of Care as defined in the Model of Care Matrix upload document.	Yes/No
2. Upload a copy of the written Model of Care.	Upload
3. Download the Model of Care Matrix Upload Document, fully complete it, and upload the completed document.	Upload

12. Health Risk Assessment Attestations

Attestation	Response
Health Risk Assessment
1. Applicant conducts a comprehensive initial health risk assessment of the medical, functional, cognitive, and psychosocial status as well as annual health risk reassessments for each beneficiary which includes some or all of the following:
a. conduct an initial comprehensive health risk assessment within 90 days of enrollment and use the results to develop the individualized care plan for each beneficiary	Yes/No
b. conduct annual comprehensive health risk assessment and the results are used to update the individualized care plan for each beneficiary	Yes/No
c. comprehensive initial and annual health risk assessment examines covers medical, psychosocial, cognitive, and functional status	Yes/No
d. comprehensive health risk assessment is conducted face-to-face by the applicant	Yes/No
e. comprehensive health risk assessment is conducted telephonically by the applicant	Yes/No
f. comprehensive health risk assessment is conducted by having the beneficiary complete an electronic or paper-based questionnaire	Yes/No
2. Applicant develops or selects and utilizes a comprehensive risk assessment tool that will be reviewed during oversight activities and consists of:
a. an existing validated health risk assessment tool	Yes/No
b. a plan-developed health risk assessment tool	Yes/No
c. an electronic health risk assessment tool	Yes/No
d. a paper health risk assessment tool	Yes/No
e. uses a standardized health risk assessment tool for all beneficiaries	Yes/No
f. periodically reviews the effectiveness of the health risk assessment tool	Yes/No
3. Upload a copy of the applicants comprehensive health risk assessment tool.
4. Applicant has a process to conduct authoritative health risk assessment, analyze identified health risks, and stratify them to develop an individualized care plan that mitigates health risks through some of the following methods:
a. Comprehensive health risk analysis is conducted by a credentialed healthcare professional	Yes/No
b. Applicant notifies the Interdisciplinary Care Team, respective providers, and beneficiary about the results of the health risk analysis	Yes/No
c. Applicant tracks and trends population health risk data to inform the development of specialized benefits and services	Yes/No
d. Applicant uses predictive modeling or other software to stratify beneficiary health risks for the development of an individualized care plan	Yes/No
e. Applicant manually analyzes health risk data to stratify beneficiary health risks for the development of an individualized care plan	Yes/No

13. Quality Improvement Program Requirements

Attestation	Response
SNP Quality Improvement Program Requirements
1. Applicant has a written plan including policies, procedures, and a systematic methodology to conduct an overall quality improvement program that is specific to its targeted special needs individuals.	Yes/No
2. Applicant has a health information system to collect, analyze, and integrate valid and reliable data to conduct its overall quality improvement program.	Yes/No
3. Applicant has a system to maintain health information for CMS review as requested.	Yes/No
4. Applicant has a system to ensure that data collected, analyzed, and reported are accurate and complete.	Yes/No
5. Applicant conducts an annual review of the effectiveness of its quality improvement program.	Yes/No
6. Applicant takes action to correct problems identified through its quality improvement activities as well as complaints from beneficiaries and providers.	Yes/No
7. Applicant conducts one or more chronic care improvement programs to improve health outcomes for beneficiaries having chronic conditions.	Yes/No
8. Applicant identifies beneficiaries with multiple or severe chronic conditions that would benefit from participation in a chronic care improvement program.	Yes/No
9. Applicant has a mechanism to monitor beneficiaries that participate in a chronic care improvement program.	Yes/No
10. Applicant conducts one or more quality improvement projects on clinical or non-clinical areas.	Yes/No
11. For each quality improvement project, applicant measures performance, applies interventions to improve performance, evaluates performance, and conducts periodic follow-up to ensure the effectiveness of the intervention.	Yes/No
12. For each quality improvement project, applicant evaluates performance using quality indicators that are objective, clearly defined, and correspond to measurable outcomes such as changes in health status, functional status, and beneficiary satisfaction.	Yes/No
13. For each quality improvement project, applicant collects, analyzes, reports, and acts on valid and reliable data, and achieves demonstrable improvement from interventions.	Yes/No
14. For each special needs plan, applicant collects, analyzes, and reports data that measure health outcomes and indices of quality pertaining to the management of care for its targeted special needs population (i.e., dual-eligible, institutionalized, or chronic condition) at the plan level.	Yes/No
15. For each special needs plan, applicant collects, analyzes, and reports data that measure access to care (e.g., service and benefit utilization rates, or timeliness of referrals or treatment).	Yes/No
16. For each special needs plan, applicant collects, analyzes, and reports data that measure improvement in beneficiary health status (e.g., quality of life indicators, depression scales, or chronic disease outcomes).	Yes/No
17. For each special needs plan, applicant collects, analyzes, and reports data that measure staff implementation of the SNP model of care (e.g., National Committee for Quality Assurance accreditation measures or medication reconciliation associated with care setting transitions indicators).	Yes/No
18. For each special needs plan, applicant collects, analyzes, and reports data that measure comprehensive health risk assessment (e.g., accuracy of acuity stratification, safety indicators, or timeliness of initial assessments or annual reassessments).	Yes/No
19. For each special needs plan, applicant collects, analyzes, and reports data that measure implementation of an individualized plan of care (e.g., rate of participation by IDT members and beneficiaries in care planning).	Yes/No
20. For each special needs plan, applicant collects, analyzes, and reports data that measure use and adequacy of a provider network having targeted clinical expertise (e.g., service claims, pharmacy claims, diagnostic reports, etc.)	Yes/No
21. For each special needs plan, applicant collects, analyzes, and reports data that measure delivery of add-on services and benefits that meet the specialized needs of the most vulnerable beneficiaries (frail, disabled, near the end-of-life, etc.).	Yes/No
22. For each special needs plan, applicant collects, analyzes, and reports data that measure provider use of evidence-based practices and/or nationally recognized clinical protocols.	Yes/No
23. For each special needs plan, applicant collects, analyzes, and reports data that measure the effectiveness of communication (e.g., call center utilization rates, rates of beneficiary involvement in care plan development, analysis of beneficiary or provider complaints, etc.).	Yes/No
24. For each special needs plan, applicant collects, analyzes, and reports data that measure CMS-required data on quality and outcomes measures that will enable beneficiaries to compare health coverage options. These data include HEDIS, HOS, and/or CAHPS data.	Yes/No
25. For each special needs plan, applicant collects, analyzes, and reports data that measure CMS-required Part C Reporting Data Elements that will enable CMS to monitor plan performance.	Yes/No
26. For each special needs plan, applicant collects, analyzes, and reports CMS-required Medication Therapy Management measures that will enable CMS to monitor plan performance.	Yes/No
27. For each special needs plan, applicants agrees to disseminate the results of the transitions of care analysis to the interdisciplinary care team.	Yes/No
28. Provide a copy of the MAO’s written plan that describes its overall quality improvement program.	Upload
29. Provide a completed copy of the Quality Improvement Program Matrix Upload Document.	Upload Quality Improvement Program Matrix Upload Document.

14. D-SNP State Medicaid Agency Contract Matrix

Please complete and upload this document into HPMS per HPMS MA Application User Guide Instructions for completed (i.e., signed) contracts with the State Medicaid Agency. This applies to previously signed contracts that are still effective due to it being a multi-year contract or an evergreen contract.
STATE CONTRACT/SUB CONTRACT REQUIREMENTS Plan Name: ____________________________ PBP: ­­__________ Date: __________________ State Contract Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­­_____________________ Service Area: ­­­­­­­­­­­­­­­­_________________________
CMS Regulations – 42 CFR 422.107 (c)	Page Number(s)	Section Number
MA organizations responsibility, including financial obligations, to provide or arrange for Medicaid benefits.
Category(ies) of eligibility for dual-eligible beneficiaries enrolled under the SNP, as described under the Statute at sections 1902(a), 1902(f), 1902(p), and 1905. All Duals: QMB, QMB+,SLMB, SLMB+,QI,QDWI, FDBE * Full Benefit Dual Eligible: QMB+, SLMB+, and FBDE* Medicare Zero-Dollar Cost Share: QMB, QMB+ Dual Eligible Subset D-SNPs: Targeted populations that align with those that are defined under the State Medicaid Plan or are approved on a case by case basis by CMS.** NOTE: If applicable, please use State aid codes to identify category of duals being enrolled. * As defined under the State Medicaid plan ** All Medicaid subsets must be defined in the State Medicaid Agency Contract
Medicaid benefits covered under the SNP
Cost-sharing protections covered under the SNP
Identification and sharing of information on Medicaid provider participation
Verification of enrollee’s eligibility for both Medicare and Medicaid
Service area covered by the SNP
The contract period for the SNP

15. Fully Integrated Dual Eligible (FIDE) Special Needs Plan (SNP) Contract

Review Matrix

Plans should use this document to identify where each FIDE SNP element is met within their contract(s). The matrix will be used to assist the Centers for Medicare and Medicaid Services (CMS) in conducting the FIDE SNP determination reviews.
FULLY INTEGRATED DUAL ELIGIBLE (FIDE) SPECIAL NEEDS PLAN (SNP) CONTRACT REVIEW MATRIX Plan Name: ____________________________ PBP: ­­__________ Date: __________________ State Contract Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­­_____________________ Service Area: ­­­­­­­­­­­­­­­­_________________________
Meeting the definition of a FIDE SNP – CMS 4144-F	Page Number(s)	Section Number
(1) Enroll special needs individuals entitled to medical assistance under a Medicaid State plan, as defined in section 1859(b)(6)(B)(ii) of the Act and § 422.2.
(2) Provide dual eligible beneficiaries access to Medicare and Medicaid benefits under a single managed care organization (MCO).
(3) Have a capitated contract with a State Medicaid agency that includes coverage of specified primary, acute and long-term care benefits and services, consistent with State policy.
(4) Coordinate the delivery of covered Medicare and Medicaid health and long term care services, using aligned care management and specialty care network methods for high-risk beneficiaries.
(5) Employ policies and procedures approved by CMS and the State to coordinate or integrate member materials, including enrollment, communications, grievance and appeals, and quality assurance.

16. I-SNP Upload Documents

I-SNP Individuals Residing Only in Institutions

Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.
I-SNP Individuals Residing Only in Institutions Upload Document
Applicants Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter CMS contract number here.
1. Provide a list of contracted long-term care facilities.
Name of Contracted Long-term Care Facilities	Medicaid Provider #	Facilities Address
Enter name of long-term care facilities here.	Enter Medicaid provider # here.	Enter facilities address here.
2. Provide attestation for Special Needs Plans (SNP) Serving institutionalized beneficiaries.
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries I attest that in the event the above referenced organization has a CMS approved institutional SNP, the organization will only enroll beneficiaries in the SNP who (1) reside in a Long Term Care (LTC) facility under contract with or owned by the organization offering the SNP to provide services in accordance with the institutional SNP Model of Care approved by CMS, or (2) agree to move to such a facility following enrollment. I further attest that the contract with all LTCs stipulates that the MAO has the authority to conduct on-site visits to observe care, review credentialing and competency assessment records, review beneficiary medical records, and meet with LTC personnel to assure quality and safe care of its beneficiaries. I attest that in the event the above referenced organization has a CMS approved institutional SNP to provide services to community dwelling beneficiaries who otherwise meet the institutional status as determined by the State, the SNP will assure that the necessary arrangements with community resources are in place to ensure beneficiaries will be assessed and receive services as specified by the SNP Model of Care. I attest that if a SNP enrollee changes residence, the SNP will have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence, or disenroll the beneficiary according to CMS enrollment/disenrollment policies and procedures. Appropriate documentation includes the executed MAO contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care. _________________________________________ ____________________________ CEO DATE

I-SNP Individuals Residing Only in the Community

Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.
I-SNP Individuals Residing Only in the Community Upload Document
Applicants Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter CMS contract number here.
1. Provide the name of the entity(ies) performing the level of care (LOC) assessment for enrolling individuals living in the community.
Enter name of the entity(ies) performing the LOC assessment here.
2. Provide the address of the entity(ies) performing the LOC assessment.
Enter the address of the entity(ies) performing the LOC assessment here.
3. Provide the relevant credential (e.g., RN for registered nurse, LSW for licensed social worker, etc.) of the staff from the entity(ies) performing the LOC assessment.
Enter the relevant credential from the staff of the entity(ies) performing the LOC assessment here.
4. Provide a list of assisted-living facilities (if applicant is contracting with ALFs)
Name of Assisted-living Facilities	Medicaid Provider #	Facilities Address
Enter Name of assisted-living facilities here.	Enter Medicaid provider # here.	Enter facilities address here.

I-SNP Individuals Residing in Both Institutions and the Community

Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.
I-SNP Individuals Residing in Both Institutions and the Community Upload Document
Applicants Contract Name (as provided in HPMS):
Enter contract name here.
CMS Contract Number:
Enter CMS contract number here.
1. For institutionalized individuals, provide a list of contracted long-term care facilities.
Name of Contracted Long-term Care Facilities	Medicaid Provider #	Facilities Address
Enter name of long-term care facilities here.	Enter Medicaid provider # here.	Enter facilities address here.
2. For institutionalized individuals, provide the following attestation by the authorized signatory.
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries I attest that in the event the above referenced organization has a CMS approved institutional SNP, the organization will only enroll beneficiaries in the SNP who (1) reside in a Long Term Care (LTC) facility under contract with or owned by the organization offering the SNP to provide services in accordance with the institutional SNP Model of Care approved by CMS, or (2) agree to move to such a facility following enrollment. I further attest that the contract with all LTCs stipulates that the MAO has the authority to conduct on-site visits to observe care, review credentialing and competency assessment records, review beneficiary medical records, and meet with LTC personnel to assure quality and safe care of its beneficiaries. I attest that in the event the above referenced organization has a CMS approved institutional SNP to provide services to community dwelling beneficiaries who otherwise meet the institutional status as determined by the State, the SNP will assure that the necessary arrangements with community resources are in place to ensure beneficiaries will be assessed and receive services as specified by the SNP Model of Care. I attest that if a SNP enrollee changes residence, the SNP will have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence, or disenroll the beneficiary according to CMS enrollment/disenrollment policies and procedures. Appropriate documentation includes the executed MAO contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care. __________________________________ ____________________________ CEO DATE
3. For institutional equivalent individuals residing in the community, provide the name, address, and relevant professional credential (e.g., RN for registered nurse, LSW for licensed social worker, etc.) of the entity(ies) performing the mandatory level of care (LOC) assessment for enrolling eligible individuals.
Name: _________________________________________________________________________________ Address: _______________________________________________________________________________ Professional Credential: ___________________________________________________________________
4. For institutional equivalent individuals residing in the community, provide a list of applicable assisted-living facilities or other residential facilities.
a. Applicant is contracting with assisted-living facilities or other residential facilities. _____ Yes _____ No
b. If applicant is contracting with assisted-living facilities or other residential facilities, enter the requested information below.
Name of Assisted-living or Other Residential Facilities	Medicaid Provider #	Facilities Address
Enter Name of assisted-living or other residential facilities here.	Enter Medicaid provider # here.	Enter facilities address here.

17. ESRD Waiver Request Upload Document

Please complete and upload this document into HPMS per the HPMS MA Application User Guide instructions.
ESRD Waiver Request Upload Document
Applicants Contract Name (as provided in HPMS):
Enter contract name here.
Applicants CMS Contract Number:
Enter contract number here.
1. Provide a description of how applicant intends to monitor and serve the unique needs of the ESRD enrollees including care coordination. Describe how/why services you provide are relevant to ESRD enrollees. Include a clinical and social profile of ESRD beneficiaries, their most frequent co-morbidities, problems with Activities of Daily Living (ADLs), living arrangements, etc.
Enter your response to #1 here.
2. Provide a description of any additional service(s) provided to members with ESRD. Include a description of how/why these services are relevant to ESRD enrollees. Only list benefits that are already required for a Medicare Advantage plan to the extent that the applicant offers enhancements to these benefit(s) that specifically address the needs of the ESRD membership. As examples, additional benefits to be described may include but are not limited to: Transportation Support groups (e.g. beneficiary; family; caregiver) Self-care education (e.g., nutrition; wound care)
Enter your response to #2 here.
3. Provide a description of the interdisciplinary care team’s coordination role in the assessment and delivery of services needed by members with ESRD. Include specific details about the interaction of the different interdisciplinary care team members during both assessment and delivery of services, and address how the interdisciplinary care team will engage the beneficiary and his/her family and caregiver(s).
Enter your response to #3 here.
4. If the applicant is delegating the ESRD care, care management, or care coordination services in any capacity to another organization the applicant must: Name the organization(s) Indicate which aspect(s) of care are delegated to each organization (health plan and delegated organization(s)), and define the areas for which each party is responsible Describe the legal relationships between the applicant and the organization(s), and Attach a copy of the fully executed contract between the health plan and the organization(s)
Enter your response to #4 here.
5. Provide a list of the contracted nephrologist(s). Beneficiary access to contracted nephrologists must meet the current HSD criteria.
Name of Contracted Nephrologist(s)	Medicare Provider #		Provider Address
Enter name of contracted nephrologist(s) here.	Enter Medicare provider # here.		Enter provider address here.
6. Provide a list of the contracted dialysis facility(ies). Beneficiary access to contracted dialysis facilities must meet the current HSD criteria.
Name of Contracted Dialysis Facility(ies)	Medicare Provider #		Facilities Address
Enter name of contracted dialysis facility(ies) here.	Enter Medicare provider # here.		Enter facilities address here.
7. Describe the dialysis options available to beneficiaries (e.g., home dialysis; nocturnal dialysis).
Enter your response to #7 here.
8. Provide a list of the contracted kidney transplant facility(ies).
Name of Contracted Kidney Transplant Facility(ies)	Medicare Provider #		Facilities Address
Enter name of contracted kidney transplant facility(ies) here.	Enter Medicare provider # here.		Enter facilities address here.
9. Describe beneficiary access to contracted kidney transplant facility(ies), including the average distance beneficiaries in each county served by the applicants SNP must travel to reach a contracted kidney transplant facility. In instances where the contracted kidney transplant facility(ies) are not within the local patterns of care for a given country, provide a justification for this deviation, and describe the transportation services and accommodations which will be made available to beneficiaries.
Enter your response to #9 here. Please use the following table to provide distance information.
County, ST		Average Distance
Enter the service area county and state (County, ST) here.		Enter the average distance (in miles) beneficiaries must travel here.

18. Model of Care Matrix Upload Document

Please complete and upload this document into HPMS per HPMS MA Application User Guide instructions.
Applicants Contract Name (as provided in HPMS)
Enter contract name here.
Applicants CMS Contract Number
Enter contract number here.
Care Management Plan Outlining the Model of Care
In the following table, list the document, page number, and section of the corresponding description in your care management plan for each model of care element.
Model of Care Elements	Corresponding Document Page Number/Section
Description of the SNP Population: The identification and comprehensive description of the SNP-specific population is an integral component of the MOC because all of the other elements depend on the firm foundation of a comprehensive population description. It must provide an overview that fully addresses the full continuum of care of current and potential SNP beneficiaries, including end-of-life needs and considerations, if relevant to the target population served by the SNP. The description of the SNP population must include, but not be limited to, the following: Clear documentation of how the health plan staff determines or will determine, verify, and track eligibility of SNP beneficiaries. A detailed profile of the medical, social, cognitive, environmental, living conditions, and co-morbidities associated with the SNP population in the plan’s geographic service area. Identification and description of the health conditions impacting SNP beneficiaries, including specific information about other characteristics that affect health such as, population demographics (e.g. average age, gender, ethnicity, and potential health disparities associated with specific groups such as: language barriers, deficits in health literacy, poor socioeconomic status, cultural beliefs/barriers, caregiver considerations, other). Define unique characteristics for the SNP population served: C-SNP: What are the unique chronic care needs for beneficiaries enrolled in a C-SNP? Include limitations and barriers that pose potential challenges for these C-SNP beneficiaries. D-SNP: What are the unique health needs for beneficiaries enrolled in a D-SNP? Include limitations and barriers that pose potential challenges for these D-SNP beneficiaries. I-SNP: What are the unique health needs for beneficiaries enrolled in an I-SNP? Include limitations and barriers that pose potential challenges for these I-SNP beneficiaries as well as information about the facilities and/or home and community-based services in which your beneficiaries reside. Sub-Population: Most Vulnerable Beneficiaries As a SNP, you must include a complete description of the specially-tailored services for beneficiaries considered especially vulnerable using specific terms and details (e.g., members with multiple hospital admissions within three months, “medication spending above $4,000”). Other information specific to the description of the most vulnerable beneficiaries must include, but not be limited to, the following: A description of the internal health plan procedures for identifying the most vulnerable beneficiaries within the SNP. A description of the relationship between the demographic characteristics of the most vulnerable beneficiaries with their unique clinical requirements. Explain in detail how the average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status and other factor(s) affect the health outcomes of the most vulnerable beneficiaries. The identification and description of the established partnerships with community organizations that assist in identifying resources for the most vulnerable beneficiaries, including the process that is used to support continuity of community partnerships and facilitate access to community services by the most vulnerable beneficiaries and/or their caregiver(s).
2. Care Coordination: Care coordination helps ensure that SNP beneficiaries’ healthcare needs, preferences for health services and information sharing across healthcare staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, and high-quality patient services that ultimately lead to improved healthcare outcomes, including services furnished outside the SNP’s provider network as well as the care coordination roles and responsibilities overseen by the beneficiaries’ caregiver(s). The following MOC sub-elements are essential components to consider in the development of a comprehensive care coordination program; no sub-element must be interpreted as being of greater importance than any other. All five sub-elements below, taken together, must comprehensively address the SNPs’ care coordination activities. SNP Staff Structure Fully define the SNP staff roles and responsibilities across all health plan functions that directly or indirectly affect the care coordination of beneficiaries enrolled in the SNP. This includes, but is not limited to, identification and detailed explanation of: Specific employed and/or contracted staff responsible for performing administrative functions, such as: enrollment and eligibility verification, claims verification and processing, other. Employed and/or contracted staff that perform clinical functions, such as: direct beneficiary care and education on self-management techniques, care coordination, pharmacy consultation, behavioral health counseling, other. Employed and/or contracted staff that performs administrative and clinical oversight functions, such as: license and competency verification, data analyses to ensure appropriate and timely healthcare services, utilization review, ensuring that providers use appropriate clinical practice guidelines and integrate care transitions protocols. Provide a copy of the SNP’s organizational chart that shows how staff responsibilities identified in the MOC are coordinated with job titles. If applicable, include a description of any instances when a change to staff title/position or level of accountability was required to accommodate operational changes in the SNP. Identify the SNP contingency plan(s) used to ensure ongoing continuity of critical staff functions. Describe how the SNP conducts initial and annual MOC training for its employed and contracted staff, which may include, but not be limited to, printed instructional materials, face-to-face training, web-based instruction, and audio/video-conferencing. Describe how the SNP documents and maintains training records as evidence to ensure MOC training provided to its employed and contracted staff was completed. For example, documentation may include, but is not limited to: copies of dated attendee lists, results of MOC competency testing, web-based attendance confirmation, and electronic training records. Explain any challenges associated with the completion of MOC training for SNP employed and contracted staff and describe what specific actions the SNP will take when the required MOC training has not been completed or has been found to be deficient in some way. Health Risk Assessment Tool (HRAT) The quality and content of the HRAT should identify the medical, functional, cognitive, psychosocial and mental health needs of each SNP beneficiary. The content of, and methods used to conduct the HRAT have a direct effect on the development of the Individualized Care Plan and ongoing coordination of Interdisciplinary Care Team activities; therefore, it is imperative that the MOC include the following: A clear and detailed description of the policies and procedures for completing the HRAT including: Description of how the HRAT is used to develop and update, in a timely manner, the Individualized Care Plan (MOC Element 2C) for each beneficiary and how the HRAT information is disseminated to and used by the Interdisciplinary Care Team (MOC Element 2D). Detailed explanation for how the initial HRAT and annual reassessment are conducted for each beneficiary. Detailed plan and rationale for reviewing, analyzing, and stratifying (if applicable) the results of the HRAT, including the mechanisms to ensure communication of that information to the Interdisciplinary Care Team, provider network, beneficiaries and/or their caregiver(s), as well as other SNP personnel that may be involved with overseeing the SNP beneficiary’s plan of care. If stratified results are used, include a detailed description of how the SNP uses the stratified results to improve the care coordination process. Individualized Care Plan (ICP) The ICP components must include, but are not limited to: beneficiary self-management goals and objectives; the beneficiary’s personal healthcare preferences; description of services specifically tailored to the beneficiary’s needs; roles of the beneficiaries’ caregiver(s); and identification of goals met or not met. When the beneficiary’s goals are not met, provide a detailed description of the process employed to reassess the current ICP and determine appropriate alternative actions. Explain the process and which SNP personnel are responsible for the development of the ICP, how the beneficiary and/or his/her caregiver(s) or representative(s) is involved in its development and how often the ICP is reviewed and modified as the beneficiary’s healthcare needs change. If a stratification model is used for determining SNP beneficiaries’ health care needs, then each SNP must provide a detailed explanation of how the stratification results are incorporated into each beneficiary’s ICP. Describe how the ICP is documented and updated as well as, where the documentation is maintained to ensure accessibility to the ICT, provider network, beneficiary and/or caregiver(s). Explain how updates and/or modifications to the ICP are communicated to the beneficiary and/or their caregiver(s), the ICT, applicable network providers, other SNP personnel and other stakeholders as necessary. Interdisciplinary Care Team (ICT) Provide a detailed and comprehensive description of the composition of the ICT; include how the SNP determines ICT membership and a description of the roles and responsibilities of each member. Specify how the expertise and capabilities of the ICT members align with the identified clinical and social needs of the SNP beneficiaries, and how the ICT members contribute to improving the health status of SNP beneficiaries. If a stratification model is used for determining SNP beneficiaries’ health care needs, then each SNP must provide a detailed explanation of how the stratification results are used to determine the composition of the ICT. Explain how the SNP facilitates the participation of beneficiaries and their caregivers as members of the ICT. Describe how the beneficiary’s HRAT (MOC Element 2B) and ICP (MOC Element 2C) are used to determine the composition of the ICT; including those cases where additional team members are needed to meet the unique needs of the individual beneficiary. Explain how the ICT uses healthcare outcomes to evaluate established processes to manage changes and/or adjustments to the beneficiary’s health care needs on a continuous basis. Identify and explain the use of clinical managers, case managers or others who play critical roles in ensuring an effective interdisciplinary care process is being conducted. Provide a clear and comprehensive description of the SNP’s communication plan that ensures exchanges of beneficiary information is occurring regularly within the ICT, including not be limited to, the following: Clear evidence of an established communication plan that is overseen by SNP personnel who are knowledgeable and connected to multiple facets of the SNP MOC. Explain how the SNP maintains effective and ongoing communication between SNP personnel, the ICT, beneficiaries, caregiver(s), community organizations and other stakeholders. The types of evidence used to verify that communications have taken place, e.g., written ICT meeting minutes, documentation in the ICP, other. How communication is conducted with beneficiaries who have hearing impairments, language barriers and/or cognitive deficiencies. Care Transitions Protocols Explain how care transitions protocols are used to maintain continuity of care for SNP beneficiaries. Provide details and specify the process and rationale for connecting the beneficiary to the appropriate provider(s). Describe which personnel (e.g., case manager) are responsible for coordinating the care transition process and ensuring that follow-up services and appointments are scheduled and performed as defined in MOC Element 2A. Explain how the SNP ensures elements of the beneficiary’s ICP are transferred between healthcare settings when the beneficiary experiences an applicable transition in care. This must include the steps that need to take place before, during and after a transition in care has occurred. Describe, in detail, the process for ensuring the SNP beneficiary and/or caregiver(s) have access to and can adequately utilize the beneficiaries’ personal health information to facilitate communication between the SNP beneficiary and/or their caregiver(s) with healthcare providers in other healthcare settings and/or health specialists outside their primary care network. Describe how the beneficiary and/or caregiver(s) will be educated about indicators that his/her condition has improved or worsened and how they will demonstrate their understanding of those indicators and appropriate self-management activities. Describe how the beneficiary and/or caregiver(s) are informed about who their point of contact is throughout the transition process.
SNP Provider Network: The SNP Provider Network is a network of healthcare providers who are contracted to provide health care services to SNP beneficiaries. Each SNP is responsible for ensuring their MOC identifies, fully describes, and implements the following for its SNP Provider Network: Specialized Expertise Provide a complete and detailed description of the specialized expertise available to SNP beneficiaries in the SNP provider network that corresponds to the SNP population identified in MOC Element 1. Explain how the SNP oversees its provider network facilities and ensures its providers are actively licensed and competent (e.g., confirmation of applicable board certification) to provide specialized healthcare services to SNP beneficiaries. Specialized expertise may include, but is not limited to: internal medicine, endocrinologists, cardiologists, oncologists,, mental health specialists, other. Describe how providers collaborate with the ICT (MOC Element 2D) and the beneficiary, contribute to the ICP (MOC Element 2C) and ensure the delivery of necessary specialized services. For example, describe: how providers communicate SNP beneficiaries’ care needs to the ICT and other stakeholders; how specialized services are delivered to the SNP beneficiary in a timely and effective way; and how reports regarding services rendered are shared with the ICT and how relevant information is incorporated into the ICP. Use of Clinical Practice Guidelines & Care Transitions Protocols Explain the processes for ensuring that network providers utilize appropriate clinical practice guidelines and nationally-recognized protocols. This may include, but is not limited to: use of electronic databases, web technology, and manual medical record review to ensure appropriate documentation. Define any challenges encountered with overseeing patients with complex healthcare needs where clinical practice guidelines and nationally-recognized protocols may need to be modified to fit the unique needs of vulnerable SNP beneficiaries. Provide details regarding how these decisions are made, incorporated into the ICP (MOC Element 2C), communicated with the ICT (MOC Element 2D) and acted upon. Explain how SNP providers ensure care transitions protocols are being used to maintain continuity of care for the SNP beneficiary as outlined in MOC Element 2E. MOC Training for the Provider Network Explain, in detail, how the SNP conducts initial and annual MOC training for network providers and out-of-network providers seen by beneficiaries on a routine basis. This could include, but not be limited to: printed instructional materials, face-to-face training, web-based instruction, audio/video-conferencing, and availability of instructional materials via the SNP plans’ website. Describe how the SNP documents and maintains training records as evidence of MOC training for their network providers. Documentation may include, but is not limited to: copies of dated attendee lists, results of MOC competency testing, web-based attendance confirmation, electronic training records, and physician attestation of MOC training. Explain any challenges associated with the completion of MOC training for network providers and describe what specific actions the SNP Plan will take when the required MOC training has not been completed or is found to be deficient in some way.
4. MOC Quality Measurement & Performance Improvement: The goals of performance improvement and quality measurement are to improve the SNP’s ability to deliver healthcare services and benefits to its SNP beneficiaries in a high-quality manner. Achievement of those goals may result from increased organizational effectiveness and efficiency by incorporating quality measurement and performance improvement concepts used to drive organizational change. The leadership, managers and governing body of a SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified based on performance results. MOC Quality Performance Improvement Plan Explain, in detail, the quality performance improvement plan and how it ensures that appropriate services are being delivered to SNP beneficiaries. The quality performance improvement plan must be designed to detect whether the overall MOC structure effectively accommodates beneficiaries’ unique healthcare needs. The description must include, but is not limited to, the following: The complete process, by which the SNP continuously collects, analyzes, evaluates and reports on quality performance based on the MOC by using specified data sources, performance and outcome measures. Details regarding how the SNP leadership, management groups and other SNP personnel and stakeholders are involved with the internal quality performance process. Details regarding how the SNP-specific measurable goals and health outcomes objectives are integrated in the overall performance improvement plan (MOC Element 4B). Measureable Goals & Health Outcomes for the MOC Identify and clearly define the SNP’s measureable goals and health outcomes and describe how identified measureable goals and health outcomes are communicated throughout the SNP organization. Responses should include but not be limited to, the following: Specific goals for improving access and affordability of the healthcare needs outlined for the SNP population described in MOC Element 1. Improvements made in coordination of care and appropriate delivery of services through the direct alignment of the HRAT, ICP, and ICT. Enhancing care transitions across all healthcare settings and providers for SNP beneficiaries. Ensuring appropriate utilization of services for preventive health and chronic conditions. Identify the specific beneficiary health outcomes measures that will be used to measure overall SNP population health outcomes, including the specific data source(s) that will be used. Describe, in detail, how the SNP establishes methods to assess and track the MOC’s impact on the SNP beneficiaries’ health outcomes. Describe, in detail, the processes and procedures the SNP will use to determine if the health outcomes goals are met or not met. Explain the specific steps the SNP will take if goals are not met in the expected time frame. C. Measuring Patient Experience of Care (SNP Member Satisfaction) Describe the specific SNP survey(s) used and the rationale for selection of that particular tool(s) to measure SNP beneficiary satisfaction. Explain how the results of SNP member satisfaction surveys are integrated into the overall MOC performance improvement plan, including specific steps to be taken by the SNP to address issues identified in response to survey results. D. Ongoing Performance Improvement Evaluation of the MOC Explain, in detail, how the SNP will use the results of the quality performance indicators and measures to support ongoing improvement of the MOC, including how quality will be continuously assessed and evaluated. Describe the SNP’s ability to improve, on a timely basis, mechanisms for interpreting and responding to lessons learned through the MOC performance evaluation process. Describe how the performance improvement evaluation of the MOC will be documented and shared with key stakeholders. E. Dissemination of SNP Quality Performance related to the MOC Explain, in detail, how the SNP communicates its quality improvement performance results and other pertinent information to its multiple stakeholders, which may include, but not be limited to: SNP leadership, SNP management groups, SNP boards of directors, SNP personnel & staff, SNP provider networks, SNP beneficiaries and caregivers, the general public, and regulatory agencies on a routine basis. This description must include, but is not limited to, the scheduled frequency of communications and the methods for ad hoc communication with the various stakeholders, such as: a webpage for announcements; printed newsletters; bulletins; and other announcement mechanisms. Identify the individual(s) responsible for communicating performance updates in a timely manner as described in MOC Element 2A.

19. Quality Improvement Program Matrix Upload Document

Please complete and upload this document into HPMS per HPMS MA Application User Guide instructions.
Applicants Contract Name (as provided in HPMS)
Enter contract name here.
Applicants CMS Contract Number
Enter contract number here.
Quality Improvement Program Plan
In the following table, list the document, page number, and section of the corresponding description of your quality improvement program components in your written plan.
Quality Improvement Program Components	Corresponding Document Page Number/Section
1. Description of the SNP-specific Target Population a. Identify the SNP-specific target population (e.g., Medicaid subset D-SNP, institutional equivalent individuals enrolled in I-SNP, diabetes C-SNP, or chronic heart failure/cardiovascular C-SNP) b. Describe the purpose of the quality improvement program in relation to the target population c. Describe how the MAO identifies and monitors the most vulnerable members of the population (i.e., frail, disabled, near the end-of-life, multiple or complex chronic conditions, or developing ESRD after enrollment) and the quality improvement activities designed for these individuals. d. Outline the components of the overall quality improvement program including the MAO’s internal activities and the following CMS required activities: Health information system to collect, analyze, and report accurate and complete data MAO-determined internal quality improvement activities Chronic care improvement program (one or more) Quality improvement project (one or more) Measurement of the effectiveness of the SNP model of care, indices of quality, and beneficiary health outcomes Collection and reporting of HEDIS measures (NCQA) Collection and reporting of Structure and Process measures (NCQA) Participation in HOS survey if enrollment meets threshold Participation in CAPHS survey if enrollment meets threshold (Wilkerson & Associates) Collection and reporting of Part C Reporting Elements (HPMS) Collection and Reporting of Part D Medication Therapy Management data
2. Health Information System a. Describe the health information system and how the system enables the MAO to: Collect, analyze, and integrate data to conduct the quality improvement program Ensure that data is accurate and complete Maintain health information for CMS review as requested Conduct annual review of the MAO’s overall quality improvement program Take action to correct problems revealed through complaints and quality improvement activities b. Describe how the MAO manages the health information system to comply with HIPAA and privacy laws, and professional standards of health information management
3. MAO-determined Internal Quality Improvement Activities a. Describe the quality improvement activities the MAO has designed that address the target population and are not specifically required by CMS. b. Describe how the MAO maintains documentation on internal quality improvement activities and makes it available to CMS if requested.
4. Chronic Care Improvement Program (CCIP) a. Describe the chronic care improvement program(s) and how CCIP(s) relate to the SNP target population b. Describe how the MAO identifies SNP beneficiaries who would benefit from participation in the CCIP(s) c. Describe how the MAO monitors the beneficiaries who participate in the CCIP(s), and how it evaluates the health outcomes, quality indices, and/or improved operational systems post-intervention.
5. Quality Improvement Projects (QIP) a. Describe the quality improvement project(s) and how QIP(s) relate to the SNP target population including: Clearly defined objectives Interventions for SNP target population Quality indices and health outcomes written as measureable outcomes b. Describe how the MAO identifies SNP beneficiaries who would benefit from participation in the QIP(s) c. Describe how the MAO monitors the beneficiaries who participate in the QIP(s) d. Describe how it evaluates the health outcomes, quality indices, and/or improved operational systems post-intervention, and achieves demonstrable improvement e. Describe how the MAO conducts systematic and periodic follow-up to assure improvements are sustained
6. SNP-specific Care Management Measurement a. Describe how the MAO will evaluate the effectiveness of its model of care including: Methodology Specific measurable performance outcomes that demonstrate improvements (e.g., access to care, beneficiary health status, staff structure and performance of roles, health risk assessment and stratification of identified needs, implementation of care plans, adequacy of provider network, use of clinical practice guidelines by providers, adequacy of the provider network, etc.) b. Describe how the MAO maintains documentation on model of care evaluation and makes it available to CMS as requested and during onsite audits. c. Describe how the MAO determines what actions to take based on the results of its model of care evaluation.
7. HEDIS and Structure & Process Measures (NCQA) a. Describe how the MAO collects and reports the required HEDIS measures and Structure & Process measures to NCQA (Note: SNPs having 30 or more enrolled members are required to report these measures) b. Describe how the MAO assures accuracy of HEDIS and Structure & Process measures. c. Describe how the MAO determines what actions to take based on the results of HEDIS data and Structure & Process measurement.
8. Health Outcomes Survey - HOS a. Describe how the MAO participates in reporting HOS (Note: MAOs having 500 or more enrolled members are required to report HOS information) b. Describe how the MAO determines what actions to take based on the HOS survey results.
9. Consumer Assessment of Healthcare Providers and Systems – CAHPS Survey (Wilkerson & Associates) a. Describe how the MAO participates in reporting CAHPS (Note: MAOs having 600 or more enrolled members are required to report CAPHS information) b. Describe how the MAO determines what actions to take based on the CAHPS survey results.
10. Part C Reporting Elements a. Describe how the MAO collects, analyzes, and reports Part C reporting data elements to CMS. b. Describe how the MAO assures accuracy of Part C reporting data elements. c. Describe how the MAO determines what actions to take based on the results of Part C reporting data elements.
11. Part D Medication Therapy Management Reporting a. Describe how the MAO collects, analyzes, and reports Medication Therapy Management measures to CMS. b. Describe how the MAO assures accuracy of Medication Therapy Management measures. c. Describe how the MAO determines what actions to take based on the results of Medication Therapy Management measurement.
12. Communication on Quality Improvement Program with Stakeholders a. Describe how the MAO will facilitate the participation of providers, the interdisciplinary care team, and beneficiaries/caregivers in its overall quality improvement program. b. Describe how the MAO will communicate improvements in care management resulting from its overall quality improvement program to all stakeholders (e.g., a webpage for announcements, printed newsletters, bulletins, announcements, etc.) c. Describe how the MAO maintains documentation on its overall quality improvement program and makes it available to CMS as requested and during onsite audits.

20. Past Performance Attestation

Attestation	Response
Past Performance
1. The Medicare Advantage plan(s) currently offered by the applicant, applicants parent organization, or subsidiary of the applicants parent organization has been operational since January 1, 2014 or earlier. (If the applicant, applicants parent organization, or a subsidiary of applicants parent organization does not have any existing contracts with CMS to operate a Medicare Advantage Plan, select “NA”.)	Yes/No/NA

3. APPENDIX II: Employer/Union-Only Group Waiver Plans (EGWPs) MAO “800 Series”

   1. Background

The MMA provides employers and unions with a number of options for providing coverage to their Medicare-eligible members. Under the MMA, these options include purchasing benefits from sponsors of prescription drug-only plans (PDPs), making special arrangements with Medicare Advantage Organizations (MAOs) and Section 1876 Cost Plans to purchase customized benefits, including drug benefits, for their members, and directly contracting with CMS to become Part D or MAO plan sponsors themselves. Each of these approaches involves the use of CMS waivers authorized under Sections 1857(i) or 1860D-22(b) of the SSA. Under this authority, CMS may waive or modify requirements that “hinder the design of, the offering of, or the enrollment in” employer-sponsored group plans. CMS may exercise its waiver authority for PDPs, MAOs and Cost Plan Sponsors that offer employer/union-only group waiver plans (EGWPs). EGWPs are also known as “800 series” plans because of the way they are enumerated in CMS systems.

Which Applicants Should Complete this Appendix?

This appendix is to be used by MAOs seeking to offer the following new “800 series” EGWPs: Private Fee-For-Service (PFFS) Plans, Local Coordinated Care Plans (CCPs), Regional Preferred Provider Organization Plans (RPPOs), and Regular Medical Savings Accounts (MSAs). CMS issues separate contract numbers for each type of offering and thus a separate application is required for each corresponding contract. However, applicants may submit one application to be eligible to offer new MA-only and new MA-PD EGWPs under the same contract number. All applications are required to be submitted electronically in the HPMS. Please follow the application instructions below and submit the required material in support of your application to offer new “800 series” EGWPs.

For waiver guidance and rules on Part C and Part D Employer contracts, see Chapter 9 of the MMCM and Chapter 12 of the Prescription Drug Benefit Manual.

2. Instructions

• New MAO applicants seeking to offer new “800 series” EGWPs are applicants that have not previously applied to offer plans to individual beneficiaries or “800 series” EGWPs.

Note: All new MAOs intending to offer Part D EGWPs (i.e., MA-PDs) must also complete the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors. The 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors must also be submitted electronically through HPMS. These requirements are also applicable to new MAOs applying to offer “800 series” Regular MSA or Demonstration MSA plans that do not intend to offer plans to individual beneficiaries in 2016. Together these documents will comprise a completed application for new MAOs. Failure to complete, if applicable, the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors, may result in a denial of the EGWP application.

• Existing MAOs that currently offer plans to individual beneficiaries under an existing contract but have not previously applied to offer EGWPs (MA-only or MA-PD) under this same contract.

Note: Existing MAOs are only required to complete this appendix.

Separate Applications Required For Each Contract Number

A separate application must be submitted for each contract number under which the MAO applicant is applying to offer new “800 series” EGWPs.

3. Request for Additional Waivers/Modification of Requirements (Optional)

As a part of the application process, applicants may submit individual waiver/modification requests to CMS. The applicant should submit this additional waiver/modification request as an upload via HPMS to the Attestation Waiver Request in the appropriate MA or Part D supplemental upload pages.

These requests must be identified as requests for additional waivers/modifications and must fully address the following items:

• Specific provisions of existing statutory, regulatory, and/or CMS policy requirement(s) the entity is requesting to be waived/modified (please identify the specific requirement (e.g., “42 CFR § 422.66,” or “Section 40.4 of Chapter 2 of the MMCM and whether you are requesting a waiver or a modification of these requirements);

• How the particular requirements hinder the design of, the offering of, or the enrollment in, the employer-sponsored group plan;

• Detailed description of the waiver/modification requested, including how the waiver/modification will remedy the impediment (i.e., hindrance) to the design of, the offering of, or the enrollment in, the employer-sponsored group plan;

• Other details specific to the particular waiver/modification that would assist CMS in the evaluation of the request; and

• Contact information (contract number, name, position, phone, fax and email address) of the person who is available to answer inquiries about the waiver/modification request.

4. Attestations

EGWP Attestation for Contract _________

1. MSA applicants:

• If applicant is seeking to offer MSA “800 series” EGWPs, applicant may designate national service areas and provide coverage to employer group members wherever they reside (i.e., nationwide). Note that CMS has not issued any waiver permitting MAOs to offer non-calendar year MSA plans. Therefore, MAOs may only offer calendar year MSA plans.

Network PFFS applicants:

• If applicant is seeking to offer individual plans in any part of a state, applicant may designate statewide service areas for its “800-series” plan of the same type (i.e. HMO, PPO or PFFS) and provide coverage to employer group members residing anywhere in the entire state. Note that all employer PFFS plans must be network based.

For Local CCP applicants:

• If applicant is seeking to offer individual plans in any part of a state, the applicant may designate statewide service areas and provide coverage to employer group members residing anywhere in the entire state.

However, to enable employers and unions to offer CCPs to all their Medicare eligible retirees wherever they reside, an MAO offering a local CCP in a given service area (i.e., a state) can extend coverage to an employer’s or union sponsor’s beneficiaries residing outside of that service area when the MAO, either by itself or through partnerships with other MAOs, is able to meet CMS provider network adequacy requirements and provide consistent benefits to those beneficiaries. Applicants who are eligible for this waiver at the time of application or who may become eligible at any time during the contract year are strongly encouraged to designate their service area broadly (e.g., multiple states, national) to allow for the possibility of enrolling members during the contract year if adequate networks are in place. No mid-year service area expansions will be permitted. Applicants offering both individual and “800 series” plans will be required to have Part C or D networks in place for those designated EGWP service areas outside of their individual plan service areas.

RPPO applicants:

• Applicants offering individual plans in any region may provide coverage to employer group members residing throughout the entire region (i.e., RPPOs must have the same service area for its EGWPs as for its individual plans).

I certify that I am an authorized representative, officer, chief executive officer, or general partner of the business organization that is applying for qualification to offer EGWPs in association with my organization’s MA contract with CMS. I have read, understand, and agree to comply with the above statement about service areas. If I need further information, I will contact one of the individuals listed in the instructions for this appendix.

{Entity MUST complete to be considered a complete application.}

2. Certification

Note: Any specific certifications below that reference Part D are not applicable to MAO applicants applying to offer an MSA product because these entities cannot offer Part D under these contracts. Entities can offer Part D benefits through a separate standalone Prescription Drug Plan (PDP); however, a separate application is required to offer “800 series” PDPs.

All provisions of the 2016 MA Applications and the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors apply to all employer/union-group waiver plan benefit packages offered by MAOs except where the provisions are specifically modified and/or superseded by particular employer/union-only group waiver guidance, including those waivers/modifications set forth below.

For existing MAOs, this appendix comprises the entire “800 series” EGWP application for MAOs.

I, the undersigned, certify to the following:

1. Applicant is applying to offer new employer/union-only group waiver (“800 series”) plans and agrees to be subject to and comply with all CMS employer/union-only group waiver guidance.

2. New MAO applicants seeking to offer an EGWP (“800 series” plan) must submit and complete the entire EGWP application for MAOs which consists of: this appendix, along with the 2016 MA Application and the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors (if applicable).

3. Applicant agrees to restrict enrollment in its EGWPs to those Medicare eligible individuals eligible for the employer’s/union’s employment-based group coverage. (See 42 CFR section 422.106(d)(2))

4. Applicant understands and agrees that it is not required to submit a 2016 Part D bid (i.e., bid pricing tool) in order to offer its EGWPs. (Section 2.7 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

5. In order to be eligible for the CMS retail pharmacy access waiver of 42 CFR § 423.120(a)(1), applicant attests that its retail pharmacy network is sufficient to meet the needs of its enrollees throughout the employer/union-only group waiver service area, including situations involving emergency access, as determined by CMS. Applicant acknowledges and understands that CMS reviews the adequacy of the applicants pharmacy networks and may potentially require expanded access in the event of beneficiary complaints or for other reasons it determines in order to ensure that the applicants network is sufficient to meet the needs of its employer group population. (See the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

6. MAO applicant understands and agrees that as a part of the underlying application, it submits a Part D retail pharmacy network list, and other pharmacy access submissions (mail order, home infusion, long-term care, I/T/U) in the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors for its designated EGWP service area at the time of application.

7. Applicant understands that its EGWPs are not included in the processes for auto-enrollment (for full-dual eligible beneficiaries) or facilitated enrollment (for other low income subsidy eligible beneficiaries).

8. Applicant understands that CMS has waived the requirement that the EGWPs must provide beneficiaries the option to pay their premiums through Social Security withholding. Thus, the premium withhold option will not be available for enrollees in 42 CFR § 422.64 and 42 CFR § 423.48 to submit information to CMS, including the requirement to submit information (e.g., pricing and pharmacy network information) to be publicly reported on www.medicare.gov, Medicare Plan Finder (“MPF”). Applicants EGWPs. (Sections 3.6.A10 and 3.24.A2-A4 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

9. Applicant understands that dissemination/disclosure materials for its EGWPs are not subject to the requirements contained in 42 CFR § 422.2262 or 42 CFR § 423.2262 to be submitted for review and approval by CMS prior to use. However, applicant agrees to submit these materials to CMS at the time of use in accordance with the procedures outlined in Chapter 9 of the MMCM. Applicant also understands CMS reserves the right to review these materials in the event of beneficiary complaints or for any other reason it determines to ensure the information accurately and adequately informs Medicare beneficiaries about their rights and obligations under the plan. (See the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

10. Applicant understands that its EGWPs is not subject to the requirements regarding the timing for issuance of certain disclosure materials, such as the Annual Notice of Change/ Evidence of Coverage (ANOC/EOC), Summary of Benefits (SB), Formulary, and LIS rider when an employer’s or union’s open enrollment period does not correspond to Medicare’s Annual Coordinated Election Period. For these employers and unions, the timing for issuance of the above disclosure materials should be appropriately based on the employer/union sponsor’s open enrollment period. For example, the Annual Notice of Change/Evidence of Coverage (ANOC/EOC), Summary of Benefits (SB), LIS rider, and Formulary are required to be received by beneficiaries no later than 15 days before the beginning of the employer/union group health plan’s open enrollment period. The timing for other disclosure materials that are based on the start of the Medicare plan (i.e., calendar) year should be appropriately based on the employer/union sponsor’s plan year. (Section 3.14.A.11 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

11. Applicant understands that the dissemination/disclosure requirements set forth in 42 CFR § 422.111 and 42 CFR § 423.128 do not apply to its EGWPs when the employer/union sponsor is subject to alternative disclosure requirements (e.g., the Employee Retirement Income Security Act of 1974 (“ERISA”)) and complies with such alternative requirements. Applicant complies with the requirements for this waiver contained in employer/union-only group waiver guidance, including those requirements contained in Chapter 9 of the MMCM. (Sections 3.14.A.1-2, 9 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

12. Applicant understands that its EGWPs are not subject to the Part D beneficiary customer service call center hours and call center performance requirements. Applicant has a sufficient mechanism is available to respond to beneficiary inquiries and provides customer service call center services to these members during normal business hours. However, CMS may review the adequacy of these call center hours and potentially require expanded beneficiary customer service call center hours in the event of beneficiary complaints or for other reasons in order to ensure that the entity’s customer service call center hours are sufficient to meet the needs of its enrollee population. (Section 3.14.A.6 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

13. Applicant understands that its EGWPs are not subject to the requirements contained in 42 CFR § 422.64 and 42 CFR § 423.48 to submit information to CMS, including the requirements to submit information (e.g., pricing and pharmacy network information) to be publicly reported on www.medicare.gov, Medicare Plan Finder (“MPF”). (Sections 3.8.A and 3.17.A.14 of the 2016 Solicitation for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors)

14. In order to be eligible for the CMS service area waiver for Local CCPs that allows an MAO to extend coverage to employer group members outside of its individual plan service area, applicant attests it has at the time of application or will have at the time of enrollment, Part C networks adequate to meet CMS requirements and is able to provide consistent benefits to those beneficiaries, either by itself or through partnerships with other MAOs. If applicant is also applying to offer Part D, applicant attests that such expanded service areas will have convenient Part D pharmacy access sufficient to meet the needs of these enrollees.

15. MSA employer/union-only group waiver plan applicants understand that they will be permitted to enroll members through a Special Election Period (SEP) as specified in Chapter 2, Section 30.4.4.1, of the MMCM.

16. This Certification is deemed to incorporate any changes that are required by statute to be implemented during the term of the contract, and any regulations and policies implementing or interpreting such statutory provisions.

17. I have read the contents of the completed application and certify that the information contained herein is true, correct, and complete. If I become aware that any information in this appendix is not true, correct, or complete, I agree to notify CMS immediately and in writing.

18. I authorize CMS to verify the information contained herein. I agree to notify CMS in writing of any changes that may jeopardize my ability to meet the qualifications stated in this appendix prior to such change or within 30 days of the effective date of such change. I understand that such a change may result in revocation of the approval.

19. I understand that in accordance with 18 U.S.C.§. 1001, any omission, misrepresentation or falsification of any information contained in this appendix or contained in any communication supplying information to CMS to complete or clarify this appendix may be punishable by criminal, civil, or other administrative actions including revocation of approval, fines, and/or imprisonment under Federal law.

20. I acknowledge that I am aware that there is operational policy guidance, including the forthcoming Call Letter, relevant to this appendix that is posted on the CMS website and that it is continually updated. Organizations submitting an application in response to this solicitation acknowledge that they will comply with such guidance at the time of application submission.

I certify that I am an authorized representative, officer, chief executive officer, or general partner of the business organization that is applying for qualification to offer EGWPs in association with my organization’s MA contract with CMS. I have read and agree to comply with the above certifications.

{Entity MUST check box to be considered a complete application.}

{Entity MUST create 800-series PBPs during plan creation and designate EGWP service areas.}

3. APPENDIX III: Employer/Union Direct Contract for MA

   1. Background

The MMA provides employers and unions with a number of options for providing medical and prescription drug coverage to their Medicare-eligible employees, members, and retirees. Under the MMA, these options include making special arrangements with MAOs and Section 1876 Cost Plans to purchase customized benefits, including drug benefits, for their members; purchasing benefits from sponsors of standalone prescription drug plans (PDPs); and directly contracting with CMS to become a Direct Contract MA, MA-PD or PDP sponsor themselves. Each of these approaches involves the use of CMS waivers authorized under Section 1857(i) or 1860D-22(b) of the SSA. Under this authority, CMS may waive or modify requirements that “hinder the design of, the offering of, or the enrollment in” employer or union-sponsored group plans.

Which Applicants Should Complete This Appendix?

This appendix is to be used by employers or unions seeking to contract directly with CMS to become a Direct Contract MAO for its Medicare-eligible active employees and/or retirees. A Direct Contract MAO can be a:

1. Coordinated Care Plan (CCP) or

2. Private Fee-For-Service (PFFS) Plan.

Please follow the application instructions below and submit the required material in support of your application.

2. Instructions

All Direct Contract MA applicants must complete and submit the following:

(1) The 2016 MA Application. This portion of the appendix is submitted electronically through the HPMS.

(2) The 2016 Part C Financial Solvency & Capital Adequacy Documentation Direct Contract MA Application. This portion of the appendix is submitted electronically through HPMS.

(3) The 2016 Direct Contract MA Attestations. This portion of the appendix is submitted electronically through HPMS. A copy of these attestations is included with this appendix.

(4) The 2016 Request for Additional Waivers/Modification of Requirements (Optional). This portion of the application is submitted electronically through HPMS. This submission is optional and should be submitted only if the Direct Contract MA applicant is seeking new waivers or modifications of CMS requirements.

All of the above enumerated submissions will comprise a completed application for new Direct Contract MA applicants. Failure to complete and submit item numbers 1 through 3 above will result in a denial of the Direct Contract MA application (item number 4 is optional, as noted above).

Please note that in addition to this Appendix, all Direct Contract MA applicants seeking to contract directly with CMS to offer Part D coverage must also complete the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors and the 2016 Solicitation for Applications for New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors.

3. Request for Additional Waivers/Modification of Requirements (Optional)

Applicants may submit individual waiver/modification requests to CMS. The applicant should submit these additional waiver/modifications via hard copy in accordance with the instructions above.

These requests must be identified as requests for additional waivers/modifications and must fully address the following items:

• Specific provisions of existing statutory, regulatory, and/or CMS policy requirement(s) the entity is requesting to be waived/modified (please identify the specific requirement (e.g., “42 CFR § 422.66,” or “Section 40.4 of Chapter 2 of the MMCM) and whether you are requesting a waiver or a modification of these requirements);

• How the particular requirements hinder the design of, the offering of, or the enrollment in, the employer-sponsored group plan;

• Detailed description of the waiver/modification requested including how the waiver/modification will remedy the impediment (i.e., hindrance) to the design of, the offering of, or the enrollment in, the employer-sponsored group plan;

• Other details specific to the particular waiver/modification that would assist CMS in the evaluation of the request; and

• Contact information (contract number, name, position, phone, fax and email address) of the person who is available to answer inquiries about the waiver/modification request.

4. Attestations

Direct Contract MA Attestations

1. SERVICE AREA REQUIREMENTS

In general, MAOs can cover beneficiaries only in the service areas in which they are state licensed and approved by CMS to offer benefits. CMS has waived these requirements for Direct Contract MA applicants (Direct Contract CCP and/or Direct Contract PFFS MAOs). Applicants can extend coverage to all of their Medicare-eligible employees/retirees, regardless of whether they reside in one or more other MAO regions in the nation. In order to provide coverage to retirees wherever they reside, Direct Contract MA applicants must set their service area to include all areas where retirees may reside during the plan year (no mid-year service area expansions will be permitted).

Direct Contract MA applicants that offer Part D (i.e., MA-PDs) will be required to submit pharmacy access information for the entire defined service area during the application process and demonstrate sufficient access in these areas in accordance with employer group waiver pharmacy access policy.

I certify that I am an authorized representative, officer, chief executive officer, or general partner of the business organization that is applying for qualification to offer a Direct Contract MA plan. I have read, understand, and agree to comply with the above statement about service areas. If I need further information, I will contact one of the individuals listed in the instructions for this appendix.

{Entity MUST check box for their application to be considered complete.}

2. Certification

All provisions of the 2016 MA Application apply to all plan benefit packages offered by Direct Contract MAO except where the provisions are specifically modified and/or superseded by particular employer/union-only group waiver guidance, including those waivers/modifications set forth below (specific sections of the 2016 MA Application that have been waived or modified for new Direct Contract MAOs are noted in parentheses).

I, the undersigned, certify to the following:

1) Applicant is applying to offer new employer/union Direct Contract MA plans and agrees to be subject to and comply with all CMS employer/union-only group waiver guidance.

2) Applicant understands and agrees that it must complete and submit the 2016 MA Application in addition to this 2016 Initial Application for Employer/Union Direct Contract MAOs application in its entirety and the Part C Financial Solvency & Capital Adequacy Documentation for Direct Contract applicants).

Note: Applicant understands and agrees that to offer prescription drug benefits, it must also submit the 2016 Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors and the 2016 Solicitation for Applications for New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors.

3) In general, an MAO must be organized and licensed under state law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each state in which it offers coverage (42 CFR § 422.400). However, CMS has waived the state licensing requirement for all Direct Contract MAOs. As a condition of this waiver, applicant understands that CMS will require such entities to meet the financial solvency and capital adequacy standards contained in this appendix. (See State Licensure Section of the 2016 MA Application)

4) Applicant agrees to restrict enrollment in its Direct Contract MA plans to those Medicare-eligible individuals eligible for the employer’s/union’s employment-based group coverage.

5) In general, MAOs must meet minimum enrollment standards as set forth in 42 CFR § 422.514(a). Applicant understands that it will not be subject to the minimum enrollment requirements set forth in 42 CFR § 422.514(a).

6) Applicant understands that dissemination/disclosure materials for its Direct Contract MAO plans are not subject to the requirements contained in 42 CFR § 422.2262 to be submitted for review and approval by CMS prior to use. However, applicant agrees to submit these materials to CMS at the time of use in accordance with the procedures outlined in Chapter 9 of the MMCM. Applicant also understands that CMS reserves the right to review these materials in the event of beneficiary complaints, or for any other reason it determines, to ensure the information accurately and adequately informs Medicare beneficiaries about their rights and obligations under the plan. (See Medicare Operations Section of the 2016 MA Application)

7) Applicant understands that its Direct Contract MA plans will not be subject to the requirements regarding the timing for issuance of certain disclosure materials, such as the Annual Notice of Change/ Evidence of Coverage (ANOC/EOC), Summary of Benefits (SB), Formulary, and LIS rider when an employer’s or union’s open enrollment period does not correspond to Medicare’s Annual Coordinated Election Period. For these employers and unions, the timing for issuance of the above disclosure materials should be appropriately based on the employer/union sponsor’s open enrollment period. For example, the Annual Notice of Change/Evidence of Coverage (ANOC/EOC), Summary of Benefits (SB), LIS rider, and Formulary are required to be received by beneficiaries no later than 15 days before the beginning of the employer/union group health plan’s open enrollment period. The timing for other disclosure materials that are based on the start of the Medicare plan (i.e., calendar) year should be appropriately based on the employer/union sponsor’s plan year. (See Medicare Operations Section of the 2016 MA Application)

8) Applicant understands that the dissemination/disclosure requirements set forth in 42 CFR § 422.111 will not apply to its Direct Contract MA plans when the employer/union sponsor is subject to alternative disclosure requirements (e.g., ERISA) and complies with such alternative requirements. Applicant agrees to comply with the requirements for this waiver contained in employer/union-only group waiver guidance, including those requirements contained in Chapter 9 of the MMCM. (See Medicare Operations Section 3.13 of the 2016 MA Application)

9) Applicant understands that its Direct Contract MA plans are not subject to the MA beneficiary customer service call center hours and call center performance requirements. Applicant has a sufficient mechanism available to respond to beneficiary inquiries and will provide customer service call center services to these members during normal business hours. However, CMS may review the adequacy of these call center hours and potentially require expanded beneficiary customer service call center hours in the event of beneficiary complaints or for other reasons in order to ensure that the entity’s customer service call center hours are sufficient to meet the needs of its enrollee population. (See Medicare Operations Section of the 2016 MA Application)

10) Applicant understands that its Direct Contract MA plans are not subject to the requirements contained in 42 CFR § 422.64 to submit information to CMS, including the requirements to submit information (e.g., pricing and provider network information) to be publicly reported on http://www.medicare.gov (Medicare Options Compare).

11) Applicant understands that the management and operations requirements of 42 CFR § 422.503(b)(4)(i)-(iii) are waived if the employer or union (or to the extent applicable, the business associate with which it contracts for benefit services) is subject to ERISA fiduciary requirements or similar state or federal law standards. However, such entities (or their business associates) are not relieved from the record retention standards applicable to other MAOs set forth in 42 CFR 422.504(d). (See Fiscal Soundness Section of the 2016 MA Application)

12) In general, MAOs must report certain information to CMS, to their enrollees, and to the general public (such as the cost of their operations and financial statements) under 42 CFR § 422.516(a). Applicant understands that in order to avoid imposing additional and possibly conflicting public disclosure obligations that would hinder the offering of employer sponsored group plans, CMS modifies these reporting requirements for Direct Contract MAOs to allow information to be reported to enrollees and to the general public to the extent required by other laws (including ERISA or securities laws) or by contract.

13) In general, MAOs are not permitted to enroll beneficiaries who do not meet the MA eligibility requirements of 42 CFR § 422.50(a), which include the requirement to be entitled to Medicare Part A. (42 CFR § 422.50(a)(1)). Applicant understands that under certain circumstances, as outlined in section 30.1.4 of Chapter 9 of the MMCM, Direct Contract MAOs are permitted to enroll beneficiaries who are not entitled to Medicare Part A into Part B-only plan benefit packages. (See Medicare Operations Section of the 2016 MA Application)

14) In general, MAOs are not permitted to enroll beneficiaries who have end-stage renal disease (ESRD). Applicant understands that under certain circumstances, as outlined in section 20.2.3 of Chapter 2 of the MMCM, Direct Contract MAOs are permitted to enroll beneficiaries who have ESRD. (See Medicare Operations Section of the 2016 MA Application)

15) This Certification is deemed to incorporate any changes that are required by statute to be implemented during the term of the contract, and any regulations and policies implementing or interpreting such statutory provisions.

16) I have read the contents of the completed application and the information contained herein is true, correct, and complete. If I become aware that any information in this appendix is not true, correct, or complete, I agree to notify CMS immediately and in writing.

17) I authorize CMS to verify the information contained herein. I agree to notify CMS in writing of any changes that may jeopardize my ability to meet the qualifications stated in this appendix prior to such change or within 30 days of the effective date of such change. I understand that such a change may result in revocation of the approval.

18) I understand that in accordance with 18 U.S.C.§.§ 1001, any omission, misrepresentation or falsification of any information contained in this appendix or contained in any communication supplying information to CMS to complete or clarify this appendix may be punishable by criminal, civil, or other administrative actions, including revocation of approval, fines, and/or imprisonment under Federal law.

19) I acknowledge that I am aware that there is operational policy guidance, including the forthcoming Call Letter, relevant to this appendix that is posted on the CMS website and that it is continually updated. Organizations submitting an application in response to this solicitation acknowledge that they will comply with such guidance should they be approved to offer employer/union-only group waiver plans in association with the organization’s MA contract with CMS.

I certify that I am an authorized representative, officer, chief executive officer, or general partner of the business organization that is applying for qualification to offer a Direct Contract MAO plan. I have read and agree to comply with the above certifications.

{Entity MUST check box for their application to be considered complete.}

5. Part C Financial Solvency & Capital Adequacy Documentation For Direct Contract MAO applicants:

Background and Instructions

An MAO generally must be licensed by at least one state as a risk-bearing entity (42 CFR 422.400). CMS has waived the requirement for Direct Contract MAOs. Direct Contract MAOs are not required to be licensed, but must meet CMS MA Part C financial solvency and capital adequacy requirements. Each Direct Contract MAO applicant must demonstrate that it meets the financial solvency requirements set forth in this appendix and provide all required information set forth below. CMS has the discretion to approve, on a case-by-case basis, waivers of such requirements if the Direct Contract MAO can demonstrate that its fiscal soundness is commensurate with its financial risk and that through other means the entity can ensure that claims for benefits paid for by CMS and beneficiaries will be covered. In all cases, CMS will require that the employers’/unions’ contracts and sub-contracts provide beneficiary hold-harmless provisions.

The information required in this Appendix must be submitted in hardcopy in accordance with the instructions above.

1. EMPLOYER/UNION ORGANIZATIONAL INFORMATION

A. Complete the information in the table below.

INDENTIFY YOUR ORGANIZATION BY PROVIDING THE FOLLOWING INFORMATION:
Type of DIRECT CONTRACT MEDICARE ADVANTAGE PLAN requested (Check all that apply): Coordinated Care Plan : HMO/POS LPPO Open Access (Non-Network) PFFS Plan Contracted Network PFFS Plan
Organization’s Full Legal Name:
Full Address Of Your Organization’s Headquarters (Street, City, State, Zip):
Tax Status: For Profit Not For Profit	Is Applicant Subject To ERISA? Yes No
Type Of Entity (Check All That Apply) : Employer Labor Union Fund Established by One or More Employers or Labor Organizations Government Church Group Publicly-Traded Corporation Privately-Held Corporation Other (list Type) _____________________________________________
Name of Your Organization’s Parent Organization, if any:
State in Which your Organization is Incorporated or Otherwise Organized to do Business:

B. Summary Description

Briefly describe the organization in terms of its history and its present operations. Cite significant aspects of its current financial, general management, and health services delivery activities. Please include the following:

1. The size of the Medicare population currently served by the applicant, and if any, the maximum number of Medicare beneficiaries that could be served by a Direct Contract MAO.

2. The manner in which benefits are currently provided to the current Medicare population served by the applicant, and if any, the number of beneficiaries in each employer sponsored group option currently made available by the Direct Contract MAO applicant and how these options are currently funded (i.e., self-funded or fully insured).

3. The current benefit design for each of the options described in B above, including premium contributions made by the employer and/or the retiree, deductibles, co-payments, or co-insurance, etc. (applicant may attach a summary plan description of its benefits or other relevant materials describing these benefits.)

4. Information about other Medicare contracts held by the applicant, (i.e., 1876, fee for service, PPO, etc.). Provide the names and contact information for all CMS personnel with whom applicant works on their other Medicare contract(s).

5. The factors that are most important to applicant in deciding to apply to become a Direct Contract MAO for its retirees and how becoming a Direct Contract MAO will benefit the applicant and its retirees.

C. If the applicant is a state agency, labor organization, or a trust established by one or more employers or labor organizations, applicant must provide the required information listed below:

State Agencies:

If applicant is a state agency, instrumentality or subdivision, please provide the relationship between the entity that is named as the Direct Contract MAO applicant and the state or commonwealth with respect to which the Direct Contract MAO applicant is an agency, instrumentality or subdivision. Also, applicant must provide the source of applicants revenues, including whether applicant receives appropriations and/or has the authority to issue debt.

Labor Organizations:

If applicant is a labor organization, including a fund or trust, please provide the relationship (if any) between applicant and any other related labor organizations such as regional, local or international unions, or welfare funds sponsored by such related labor organizations. If applicant is a jointly trusted Taft-Hartley fund, please include the names and titles of labor-appointed and management-appointed trustees.

Trusts:

If applicant is a trust such as a voluntary employee beneficiary association under Section 501(c)(9) of the Internal Revenue Code, please provide the names of the individual trustees and the bank, trust company or other financial institution that has custody of applicants assets.

D. Policymaking Body (42 CFR 422.503(b)(4)(i)-(iii)

In general, an entity seeking to contract with CMS as a Direct Contract MAO must have policymaking bodies exercising oversight and control to ensure actions are in the best interest of the organization and its enrollees, appropriate personnel and systems relating to medical services, administration and management, and at a minimum an executive manager whose appointment and removal are under the control of the policymaking body.

An employer or union directly contracting with CMS as a Direct Contract MAO may be subject to other, potentially different standards governing its management and operations, such as the Employee Retirement Income Security Act of 1974 (“ERISA”) fiduciary requirements, state law standards, and certain oversight standards created under the Sarbanes-Oxley Act. In most cases, they will also contract with outside vendors (i.e., business associates) to provide health benefit plan services. To reflect these issues and avoid imposing additional (and potentially conflicting) government oversight that may hinder employers and unions from considering applying to offer Direct Contract MA Plans, the management and operations requirements under 42 CFR 422.503(b)(4)(i)-(iii) are waived if the employer or union (or to the extent applicable, the business associate with which it contracts for health benefit plan services) is subject to ERISA fiduciary requirements or similar state or federal laws and standards. However, such entities (or their business associates) are not relieved from the record retention standards applicable to other MAOs.

In accordance with the terms of this waiver, please provide the following information:

1. List the members of the organization's policymaking body (name, position, address, telephone number, occupation, term of office and term expiration date). Indicate whether any of the members are employees of the applicant.

2. If the applicant is a line of business rather than a legal entity, does the Board of Directors of the corporation serve as the policymaking body of the organization? If not, describe the policymaking body and its relationship to the corporate board.

3. Does the Federal Government or a state regulate the composition of the policymaking body? If yes, please identify all Federal and state regulations that govern your policymaking body (e.g., ERISA).

II. FINANCIAL SOLVENCY

1. Please provide a copy of the applicants most recent independently certified audited statements.

2. Please submit an attestation signed by the Chairman of the Board, Chief Executive Officer and Chief Financial Officer or Trustee or other equivalent official attesting to the following:

1. The applicant will maintain a fiscally sound operation and will notify CMS within 10 business days if it becomes fiscally unsound during the contract period.

2. The applicant is in compliance with all applicable Federal and state requirements and is not under any type of supervision, corrective action plan, or special monitoring by the Federal or state government or a state regulator. Note: If the applicant cannot attest to this compliance, a written statement of the reasons must be provided.

III. FINANCIAL DOCUMENTATION

1. Minimum Net Worth at the Time of Application - Documentation of Minimum Net Worth

At the time of application, the applicant must demonstrate financial solvency through furnishing two years of independently audited financial statements to CMS. These financial statements must demonstrate a required minimum net worth at the time of application of the greater of $3.0 million or the number of expected individuals to be covered under the Direct Contract MAO Plan times (X) $800.00. Complete the following:

1. Minimum Net Worth: $

2. Number of expected individuals to be covered under the Direct Contract

MAO Plan times (X) $800.00 = $______________________.

Note: If the Direct Contract MAO applicant is also applying to offer a Direct Contract MAO that provides Part D coverage (i.e., MA-PD), it must complete and submit the corresponding Direct Contract MA-PD application with this appendix and meet the Part D Minimum Net Worth requirements stated in the separate Direct Contract MA-PD application.

If the applicant has not been in operation at least twelve months, it may choose to: 1) obtain independently audited financial statements for a shorter time period; or 2) demonstrate that it has the minimum net worth through presentation of un-audited financial statements that contain sufficient detail to allow CMS to verify the validity of the financial presentation. The un-audited financial statements must be accompanied by an actuarial opinion from a qualified actuary regarding the assumptions and methods used in determining loss reserves, actuarial liabilities and related items.

A “qualified actuary” for purposes of this appendix means a member in good standing of the American Academy of Actuaries, a person recognized by the Academy as qualified for membership, or a person who has otherwise demonstrated competency in the field of actuarial science and is satisfactory to CMS.

If the Direct Contract MAO applicants auditor is not one of the 10 largest national accounting firms in accordance with the list of the 100 largest public accounting firms published by the CCH Public Accounting Report, the applicant should enclose proof of the auditor’s good standing from the relevant state board of accountancy.

1. Minimum Net Worth On and After Effective Date of Contract

The applicant must have net worth as of the effective date of the contract of the greatest of the following financial thresholds; $3.0 Million; or, an amount equal to eight percent of annual health care expenditures, using the most recent financial statements filed with CMS; or the number of expected individuals to be covered under the Direct Contract MAO Plan times (X) $800.00.

2. Liquidity at the Time of Application ($1.5 Million)

The applicant must have sufficient cash flow to meet its financial obligations as they become due. The amount of the minimum net worth requirement to be met by cash or cash equivalents is $1.5 Million. Cash equivalents are short-term highly liquid investments that can be readily converted to cash. To be classified as cash equivalents, investments must have a maturity date not longer than three months from the date of purchase.

Note: If the Direct Contract MAO applicant is also applying to offer a Direct Contract MA Plan that provides Part D coverage (i.e., MA-PD), it must complete and submit the corresponding Direct Contract MA-PD application and meet the Part D Liquidity requirements stated in the separate Direct Contract MA-PD application.

3. Liquidity On and After Effective Date of Contract

After the effective date of the contract, an applicant must maintain the greater of $1.5 Million or 40 percent of the minimum net worth requirement outlined in Section III.B above in cash or cash equivalents.

In determining the ability of an applicant to meet the requirements of this paragraph D, CMS will consider the following:

1. The timeliness of payment;

2. The extent to which the current ratio is maintained at 1:1 or greater, or whether there is a change in the current ratio over a period of time; and

3. The availability of outside financial resources.

CMS may apply the following corresponding corrective remedies:

1. If a Direct Contract MAO fails to pay obligations as they become due, CMS will require the Direct Contract MAO to initiate corrective action to pay all overdue obligations.

2. CMS may require the Direct Contract MAO to initiate corrective action if either of the following is evident:

1. The current ratio declines significantly; or

2. There is a continued downward trend in the current ratio.

The corrective action may include a change in the distribution of assets, a reduction of liabilities, or alternative arrangements to secure additional funding to restore the current ratio to at least 1:1.

3. If there is a change in the availability of outside resources, CMS will require the Direct Contract MAO to obtain funding from alternative financial resources.

4. Methods of Accounting

A Direct Contract MAO applicant generally must use the standards of Generally Accepted Accounting Principles (GAAP). GAAP are those accounting principles or practices prescribed or permitted by the Financial Accounting Standards Board. However, a Direct Contract MAO whose audited financial statements are prepared using accounting principles or practices other than GAAP, such as a governmental entity that reports in accordance with the principles promulgated by the Governmental Accounting Standards Board (GASB), may utilize such alternative standard.

5. Bonding and Insurance

An applicant may request a waiver in writing of the bonding and/or insurance requirements set forth at 42 CFR 422.503(b)(4)(iv) and (v). Relevant considerations will include demonstration that either or both of the foregoing requirements are unnecessary based on the entity’s individualized circumstances, including maintenance of similar coverage pursuant to other law, such as the bonding requirement at ERISA Section 412. If the waiver request is based on the existence of alternative coverage, the applicant must describe such alternative coverage and enclose proof of the existence of such coverage.

6. Additional Information

A Direct Contract MAO applicant must furnish the following financial information to CMS to the extent applicable:

1. Self-Insurance/Self Funding- If the Direct Contract MAO applicants PFFS Plan(s) will be self-insured or self-funded, it must forward proof of stop-loss coverage (if any) through copies of policy declarations.

2. Trust- If the Direct Contract MAO applicant maintains one or more trusts with respect to its health plan(s), a copy of the trust documents, and if the trust is intended to meet the requirements of Section 501(c)(9) of the Internal Revenue Code, the most recent IRS approval letter.

3. Forms 5500 and M-1- The two most recent annual reports on Forms 5500 and M-1 (to the extent applicable) for the Direct Contract MAO applicants health plans that cover prescription drugs for individuals who are Part D eligible.

4. ERISA Section 411(a) Attestation- The Direct Contract MAO (including a Direct Contract MAO that is exempt from ERISA) must provide a signed attestation that no person serves as a fiduciary, administrator, trustee, custodian, counsel, agent, employee, consultant, adviser or in any capacity that involves decision-making authority, custody, or control of the assets or property of any employee benefit plan sponsored by the Direct Contract MAO applicant, if he or she has been convicted of, or has been imprisoned as a result of his or her conviction, of one of the felonies set forth in ERISA Section 411(a), for 13 years after such conviction or imprisonment (whichever is later).

5. Defined Benefit Pension Plan- If the Direct Contract MAO applicant sponsors one or more defined benefit pension plans (within the meaning of ERISA Section 3(35)) that is subject to the requirements of Title IV of ERISA, the latest actuarial report for each such plan.

6. Multi-Employer Pension Plan- If the Direct Contract MAO applicant is a contributing employer with respect to one or more multi-employer pension plans within the meaning of ERISA Section 3(37), the latest estimate of contingent withdrawal liability.

7. Tax-Exempt Direct Contract MAOs (Only)- a copy of the most recent IRS tax-exemption.

IV. INSOLVENCY REQUIREMENTS

A. Hold Harmless and Continuation of Coverage/Benefits.

The Direct Contract MAO shall be subject to the same hold harmless and continuation of coverage/benefit requirements as other MAOs.

B. Deposit Requirements - Deposit at the Time of Application

A Direct Contract MAO generally must forward confirmation of its establishment and maintenance of a deposit of at least $1.0 Million to be held in accordance with CMS requirements by a qualified U.S. financial institution. A “qualified financial institution” means an institution that:

1. Is organized or (in the case of a U.S. office of a foreign banking organization) licensed, under the laws of the United States or any state thereof; and

2. Is regulated, supervised, and examined by the U.S. Federal or state authorities having regulatory authority over banks and trust companies.

The purpose of this deposit is to help ensure continuation of services, protect the interest of Medicare enrollees, and pay costs associated with any receivership or liquidation. The deposit may be used to satisfy the minimum net worth requirement set forth in Section III above.

A Direct Contract MAO may request a waiver in writing of this requirement.

Note: In addition to the requirements in this appendix, if the Direct Contract MAO is also applying to offer a Direct Contract MA Plan that provides Part D coverage (i.e., MA-PD), it must complete and submit the corresponding Direct Contract MA-PD application within this appendix and meet the Part D Deposit requirements stated in the separate Direct Contract MA-PD application.

Deposit On and After Effective Date of Contract

Based on the most recent financial statements filed with CMS, CMS will determine the adequacy of the deposit under this Section and inform the Direct Contract MAO as to the necessity for any increased deposit. Factors CMS will consider shall include the total amount of health care expenditures during the applicable period, the amount of expenditures that are uncovered, and the length of time necessary to pay claims.

Rules Concerning Deposit

1. The deposit must be held in trust and restricted for CMS’ use in the event of insolvency to pay related costs and/or to help ensure continuation of services.

2. All income from the deposit are considered assets of the Direct Contract MAO and may be withdrawn from the deposit upon CMS’ approval. Such approval is not to be withheld unreasonably.

3. On prior written approval from CMS, a Direct Contract MAO that has made a deposit under this Section may withdraw such deposit or any part thereof if:

1. a substitute deposit of cash or securities of equal amount and value is made;

2. the fair market value of the assets held in trust exceeds the required amount for the deposit; or

3. the required deposit is reduced or eliminated.

V. GUARANTEES (only applies to an applicant that utilizes a Guarantor)

A. General policy

The Direct Contract PFFS MAO, or the legal entity of which the Direct Contract PFFS MAO is a component, may apply to CMS to use the financial resources of a Guarantor for the purpose of meeting the requirements of a Direct Contract MAO set forth above. CMS has the sole discretion to approve or deny the use of a Guarantor.

B. Request to Use a Guarantor

To apply to use the financial resources of a Guarantor, a Direct Contract MAO must submit to CMS:

1. Documentation that the Guarantor meets the requirements for a Guarantor under paragraph (C) of this section; and

2. The Guarantor's independently audited financial statements for the current year-to-date and for the two most recent fiscal years. The financial statements must include the Guarantor's balance sheets, profit and loss statements, and cash flow statements.

C. Requirements for Guarantor

To serve as a Guarantor, an organization must meet the following requirements:

1. Be a legal entity authorized to conduct business within a state of the United States.

2. Not be under Federal or state bankruptcy or rehabilitation proceedings.

3. Have a net worth (not including other guarantees, intangibles and restricted reserves) equal to three times the amount of the Direct Contract PFFS MAO guarantee.

4. If a state insurance commissioner or other state official with authority for risk-bearing entities regulates the Guarantor, it must meet the net worth requirement in Section III above with all guarantees and all investments in and loans to organizations covered by guarantees excluded from its assets.

5. If the Guarantor is not regulated by a state insurance commissioner or other similar state official, it must meet the net worth requirement in Section III above with all guarantees and all investments in and loans to organizations covered by a guarantee and to related parties (subsidiaries and affiliates) excluded from its assets.

D. Guarantee Document

If the guarantee request is approved, a Direct Contract MAO must submit to CMS a written guarantee document signed by an appropriate Guarantor. The guarantee document must:

1. State the financial obligation covered by the guarantee;

2. Agree to:

1. Unconditionally fulfill the financial obligation covered by the guarantee; and

2. Not subordinate the guarantee to any other claim on the resources of the Guarantor;

3. Declare that the Guarantor must act on a timely basis, in any case not more than five business days, to satisfy the financial obligation covered by the guarantee; and

4. Meet any other conditions as CMS may establish from time to time.

E. Ongoing Guarantee Reporting Requirements

A Direct Contract MAO must submit to CMS the current internal financial statements and annual audited financial statements of the Guarantor according to the schedule, manner, and form that CMS requires.

F. Modification, Substitution, and Termination of a Guarantee

A Direct Contract MAO cannot modify, substitute or terminate a guarantee unless the Direct Contract MAO:

1. Requests CMS' approval at least 90 days before the proposed effective date of the modification, substitution, or termination;

2. Demonstrates to CMS' satisfaction that the modification, substitution, or termination will not result in insolvency of the Direct Contract MAO; and

3. Demonstrates how the Direct Contract MAO will meet the requirements of this Section.

G. Nullification

If at any time the Guarantor or the guarantee ceases to meet the requirements of this section, CMS will notify the Direct Contract MAO that it ceases to recognize the guarantee document. In the event of this nullification, a Direct Contract MAO must:

1. Meet the applicable requirements of this section within 15 business days; and

2. If required by CMS, meet a portion of the applicable requirements in less than the 15 business days in paragraph (G.1.) of this section.

VI. ONGOING FINANCIAL SOLVENCY/CAPITAL ADEQUACY REPORTING REQUIREMENTS

An approved Direct Contract MAO is required to update the financial information set forth in Sections III and IV above to CMS on an ongoing basis. The schedule, manner, form and type of reporting, will be in accordance with CMS requirements.

3. APPENDIX IV: Medicare Cost Plan Service Area Expansion Application

1. State Licensure

To ensure that all Cost Plan contractors operate in compliance with state and federal regulations, CMS requires Cost Plan contractors to be licensed under state law. This will ensure that Cost Plan contractors adhere to state regulations aimed at protecting Medicare beneficiaries. The following attestations were developed based on regulations at 42 CFR 417.404.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: STATE LICENSURE	YES	NO	N/A
Applicant is licensed under State law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each State in which the applicant proposes to offer the managed care product. In addition, the scope of the license or authority allows the applicant to offer the type of managed care product that it intends to offer in the state or states. If “Yes”, upload in HPMS an executed copy of a state license certificate and the CMS State Certification Form for each state being requested. Note: Applicant must meet and document all applicable licensure and certification requirements no later than the applicants final upload opportunity, which is in response to CMS’ NOID communication.
Applicant is currently under some type of supervision, corrective action plan or special monitoring by the State licensing authority in any State. This means that the applicant has to disclose actions in any state against the legal entity which filed the application. If “Yes”, upload in HPMS an explanation of the specific actions taken by the State licensing authority.
Applicant conducts business as "doing business as" (d/b/a) or uses a name different than the name shown on its Articles of Incorporation.  If “Yes”, upload in HPMS a copy of the state approval for the d/b/a.
For states or territories whose license(s) renew after the first Monday in June, applicant agrees to (1) upload, in place of the license, a copy of its completed license renewal application or other documentation (e.g., invoice from payment of renewal fee) to show that the renewal process is being completed in a timely manner, and (2) electronically send a copy of the renewed license to the CMS Regional Office Account Manager promptly upon issuance and no later than 12/31/15. Note: If the applicant does not have a license that renews after the first Monday in June, then the applicant should respond "N/A".
Applicant has marketing representatives and/or agents who are licensed or regulated by the State in which the proposed service area is located. If the State in which the proposed service area is located doesn’t require marketing representatives/agents to be licensed, applicant should respond “N/A”.

2. In HPMS, upload an executed copy of the State Licensing Certificate and the CMS State Certification Form for each state being requested, if applicant answers “Yes” to the corresponding question above.

3. In HPMS, upload the State Corrective Plans / State Monitoring Explanation (as applicable), if applicant answers “Yes” to the corresponding question above.

4. In HPMS, upload the State Approval for d/b/a, if applicant answers “Yes” to the corresponding question above.

2. Service Area

The purpose of the service area attestation is to clearly define which areas will be served by the MAO. A service area for local plans is defined as a geographic area composed of a county or multiple counties, while a service area for MA regional plans is a region approved by CMS. The following attestation was developed to implement the regulations of 42 CFR 422.2.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: SERVICE AREA	YES	NO
Applicant meets the county integrity rule as outlined in Chapter 4 of the MMCM and will serve the entire county. If "No”, complete CMS’ Partial County Justification document.

Note: Applicant may only designate or request a partial county service area during the initial application submission.

2. In HPMS, on the Contract Management/Contract Service Area/Service Area Data page, enter the state and county information for the area the applicant proposes to serve. Applicants that do not meet the county integrity rule and applying for a partial county must complete CMS’ Partial County Justification document.

3. CMS Provider Participation Contracts & Agreements

This section contains attestations that address the requirements of 42 CFR 422.504, which requires that MAOs have oversight for contractors, subcontractors, and other entities. The intent of the regulations is to ensure services provided by these parties meet contractual obligations, laws, regulations and CMS instructions. The MAO is held responsible for compliance of its providers and subcontractors with all contractual, legal, regulatory, and operational obligations. Beneficiaries shall be protected from payment or fees that are the obligation of the MAO. Further guidance is provided in Chapter 11 of the MMCM.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: PROVIDER CONTRACTS AND AGREEMENTS	YES	NO
Applicant has executed provider, facility, and supplier contracts in place to demonstrate adequate access and availability of covered services throughout the requested service area.
Applicant agrees to have all provider contracts and/or agreements available upon request.

4. Contracts for Administrative & Management Services

This section describes the requirements the applicant must demonstrate to ensure any contracts for administrative/management services comply with the requirements of all Medicare laws, regulations, and CMS instructions in accordance with 42 CFR 417.412. Further guidance is provided in Chapter 11 of the MMCM.

1. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: CONTRACTS FOR ADMINISTRATIVE MANAGEMENT SERVICES	YES	NO
Applicant has contracts with related entities, contractors and subcontractors (first tier, downstream, and related entities) to perform, implement or operate any aspect of the Cost Plan operations.
Applicant has administrative/management contract/agreement with a delegated entity to manage/handle all staffing needs with regards to the operation of all or a portion of the Cost Plan.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of the systems or information technology to operate the Cost Plan.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of the claims administration, processing and/or adjudication functions.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of the enrollment, disenrollment and membership functions.
Applicant has an administrative/management contract/agreement with a delegated entity to perform any and/or all marketing including delegated sales broker and agent functions.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of the credentialing functions.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of call center operations.
Applicant has an administrative/management contract/agreement with a delegated entity to perform all or a portion of the financial services.
Applicant has an administrative/management contract/agreement with a delegated entity to delegate all or a portion of other services that are not listed.
Applicant agrees that as it implements, acquires, or upgrades health information technology (HIT) systems, where available, the HIT systems and products will meet standards and implementation specifications adopted under section 3004 of the Public Health Services Act as added by section 13101 of the American Recovery and Reinvestment Act of 2009, P.L. 111-5.

2. In HPMS, enter the Delegated Business Functions under the Part C Data Link.

Note: If the applicant plans to delegate a specific function but cannot at this time name the entity with which the applicant will contract, enter "Not Yet Determined" so that CMS is aware of the applicants plans to delegate that function. If the applicant delegates a particular function to a number of different entities (e.g., claims processing to multiple medical groups), then list the five most significant entities for each delegated business function identified and in the list for the sixth, enter "Multiple Additional Entities". 

5. Health Services Management & Delivery

The purpose of the Health Service Management and Delivery attestations is to ensure that all applicants deliver timely and accessible health services for Medicare beneficiaries. CMS recognizes the importance of ensuring continuity of care and developing policies for medical necessity determinations. In efforts to accomplish this, Cost Plan contractors will be required to select, evaluate, and credential providers that meet CMS’ standards, in addition, to ensuring the availability of a range of providers necessary to meet the health care needs of Medicare beneficiaries. The following attestations were developed to implement the regulations of 42 CFR 417.414, 417.416.

A. In HPMS, complete the table below:

RESPOND ‘YES’ OR ‘NO’ TO EACH OF THE FOLLOWING STATEMENTS: HEALTH SERVICES MANAGEMENT AND DELIVERY	YES	NO
Applicant agrees to establish, maintain, and monitor the performance of a comprehensive network of providers to ensure sufficient access to Medicare covered services as well as supplemental services offered by the MAO in accordance with written policies, procedures, and standards for participation established by the MAO. Participation status will be revalidated at appropriate intervals as required by CMS regulations and guidelines.
Applicant has executed written agreements with providers (first tier, downstream, or other entity instruments) structured in compliance with CMS regulations and guidelines.
Applicant, through its contracted or deemed participating provider network, along with other specialists outside the network, community resources or social services within the MAO’s service area, agrees to provide ongoing primary care and specialty care as needed and guarantee the continuity of care and the integration of services through: Prompt, convenient, and appropriate access to covered services by enrollees 24 hours a day, 7 days a week; The coordination of the individual care needs of enrollees in accordance with policies and procedures as established by the applicant; Enrollee involvement in decisions regarding treatment, proper education on treatment options, and the coordination of follow-up care; Effectively addressing and overcoming barriers to enrollee compliance with prescribed treatments and regimens; and Addressing diverse patient populations in a culturally competent manner.
Applicant agrees to establish policies, procedures, and standards that: Ensure and facilitate the availability, convenient and timely access to all Medicare covered services as well as any supplemental services offered by the MAO; Ensure access to medically necessary care and the development of medically necessary individualized care plans for enrollees; Promptly and efficiently coordinate and facilitate access to clinical information by all providers involved in delivering the individualized care plan of the enrollee; Communicate and enforce compliance by providers with medical necessity determinations; and Do not discriminate against Medicare enrollees.
Applicant has verified that contracted providers included in the MA Facility Table are Medicare certified and the applicant certifies that it will only contract with Medicare certified providers in the future.
Applicant agrees to provide all services covered by Medicare Part A and Part B and to comply with CMS national coverage determinations, general coverage guidelines included in Original Medicare manuals and instructions, and the written coverage decisions of local Medicare contractors with jurisdiction for claims in the geographic service area covered by the MAO.
Applicant agrees that all “applicable” contracted physicians/providers listed in the Provider Table have admitting privileges, as appropriate, (other than courtesy privileges) at a contracted facility.
Applicant agrees that it will provide all medically necessary transplant services to its Medicare enrollees in full agreement with the CMS guidance found in Chapter 4, Benefits and Beneficiary Protections, Medicare Managed Care Manual (Rev. 115, 08-23-13) at 10.11.
Applicants offering coordinated care plans agree that when providing transplant services at clinical locations outside of the plan’s service area, in accordance with the provisions of Chapter 4, Benefits and Beneficiary Protections, Medicare Managed Care Manual (Rev. 115, 08-23-13) at 10.11, the applicant will arrange for and pay for reasonable accommodation and transportation for the enrollee/patient and a companion.

B. In HPMS, upload the following completed HSD tables:

• MA Provider Table

• MA Facility Table

6. Part C Application Certification

1. In HPMS, upload a completed and signed Adobe.pdf format copy of the Part C Application Certification Form.

Note: Once the Part C application is complete, applicants seeking to offer a Part D plan must complete the Part D application in HPMS. PFFS and Cost Plan SAE organizations have the option to offer Part D plans. MSAs are not allowed to offer Part D plans.

7. Full Financial Risk

1. In HPMS, upload a description of any risk sharing with providers and provide physician incentive plans (PIP) disclosure for the new providers in the expanded areas.

8. Budget Forecast

1. In HPMS, upload a copy of the Cost Budget for the expanded service area.

Note: The cost budget must be based on the Cost plan financial and statistical records that can be verified by qualified auditors. The cost data must be based on an approved method of cost finding and on the accrual method of accounting.

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