You must provide female members with direct access to a women’s health specialist for routine and preventive health care services.
You must make sure members have adequate access to covered health services.
You must make sure your hours of operation are convenient to members.
You must make sure medically necessary services are available to members 24 hours a day, 7 days a week.
PCPs must have backups for absences.
You must adhere to CMS marketing regulations and guidelines. This includes, but is not limited to, the requirements to remain neutral and objective when assisting with enrollment decisions, which should always result in a plan selection in the Medicare beneficiary’s best interest. CMS marketing guidance also requires that providers must not make phone calls or direct, urge, or attempt to persuade Medicare beneficiaries to enroll or disenroll in a specific plan based on the health care provider’s financial or any other interest. You may only make available or distribute benefit plan marketing materials to members in accordance with CMS requirements.
You must provide services to members in a culturally competent manner taking into account adjustments for members who use English as a second language, hearing or vision impairment, and diverse cultural and ethnic backgrounds.
You must cooperate with our procedures to tell members of health care needs that require follow-up and provide necessary training to members in self-care.
You must document in a prominent part of the member’s medical record whether they have executed an advance directive.
You must provide covered health services in a manner consistent with professionally recognized standards of health care.
You must make sure any payment and incentive arrangements with subcontractors are specified in a written agreement, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards.
You must comply with all applicable federal and Medicare laws, regulations, and CMS instructions, including but not limited to: (a) federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including but not limited to, applicable provisions of federal criminal law, the False Claims Act, and the Anti-Kickback Statute; and (b) HIPAA administrative simplification rulesat 45 CFR Parts 160, 162 and 164.
The payments you receive from us or on behalf of us are, in whole or in part, from federal funds and you are therefore subject to certain laws applicable to individuals and entities receiving federal funds.
You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the MA program and disclose all information determined by CMS to be necessary to assist members in making an informed choice about Medicare coverage.
You must comply with our processes for notifying members if your Agreement terminates.
You must submit all Risk Adjustment Data(see definition in glossary), and other MA program and commercial insurance related information we may request, within the time frames specified and in a form that meets MA program requirements as well as state and federal commercial insurance requirements. By submitting data to us, you represent to us, and upon our request you shall certify in writing, that the data is accurate, complete, and truthful, based on your best knowledge, information and belief.
You must comply with our MA policy guidelines, coverage summaries, quality improvement programs, and medical management procedures.
You must cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance, and other indicators as specified by CMS.
You must cooperate with our procedures for handling grievances, appeals and expedited appeals. This includes, but is not limited to, providing requested medical records within 2 hours for expedited appeals and 24 hours for standard appeals, including weekends and holidays.
You must comply with the Medicare Advantage Regulatory Requirements Appendix (MARRA) in your Provider Agreement.
Member communication (CMS approval required)
Member communications require CMS approval. This includes:
Anything with the MA and/or the AARP name or logo, including MA Dual Special Needs Plans.
Correspondence that describes benefits.
Approval is not necessary for communications between health care providers and patients that discuss:
Their medical condition.
Treatment plan and/or options.
Information about managing their medical care.
Once CMS approves, we send the letter to the member.
In addition to making sure the letter is approved by the governing regulatory body, we direct the letter to the correct audience. For example, we may need to distinguish a mailing to MA plan individual members versus Medicare group retiree members, as their benefits are distinctly different.
Part C reporting requirements
MA organizations are subject to additional reporting requirements. We may request data from you. This data is due by 11:59 p.m. PT on our established reporting deadline.
Some measures are reported annually, while others are reported quarterly or semi-annually. This includes, but is not limited to:
Organization determinations/reconsiderations including source data for all determinations and reopenings.