CMS DUAL ELIGIBLE PILOT PROGRAM
The provisions of this Addendum apply to services rendered by PROVIDER to members of a Contracted Plan that is a participant in CMS’ duals program. Accordingly, PROVIDER agrees to comply with the following requirements under the CMS Dual Eligible Pilot program:
HHS, the Comptroller General or their designees shall have the right to audit, evaluate and inspect any pertinent information including books, contracts, records, including medical records, and documentation related to CMS’ contract with Contracted Plan for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later. [42 C.F.R. § 422.504(i)(2)(i) and (ii)].
The Parties will comply with confidentiality and Member record accuracy requirements, including: (1) abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information, (2) ensuring that medical information is released in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas, (3) maintaining the records and information in an accurate and timely manner, and (4) ensuring timely access by Members to the records and information that pertain to them. [42 C.F.R. §§ 422.118 and 422.504(a)(13)].
Members may not be held liable for payment of any fees that are the legal obligation of Contracted Plan. [42 C.F.R. §§ 422.504(g)(1)(i) and 422.504(i)(3)(i)].
Members eligible for both Medicare and Medicaid will not be held liable for Medicare Part A and B cost sharing. Medicare Parts A and B services must be provided at zero cost-sharing as part of the integrated package of benefits. [Guidance issued by CMS on March 29, 2012].
Any services or other activities performed by the Parties must be consistent and comply with Contracted Plan’s contractual obligations. [42 C.F.R. § 422.504(i)(3)(iii)].
Contracted Plan is obligated to pay IPA/IPA Providers under the terms of this Agreement. Section 4.6 of this Agreement contains a prompt payment provision, the terms of which have been developed and agreed to by both Plan and IPA. [42 C.F.R. § 422.520(b)].
Services must be provided in a culturally competent manner to all Members, including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds. [42 C.F.R. § 422.112(a)(8)].
If Plan has delegated the selection of providers, Plan retains the right to approve, suspend, or terminate such arrangement. [42 C.F.R. § 422.504(i)(5)].
If applicable, delegated activities and reporting responsibilities delegated hereunder, if any, are set forth in Sections 3.2, 3.3, 3.4, 3.5, 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.12, 3.13, 7.1, and 7.2, of the Agreement. [42 C.F.R. § 422.504(i)(4)(i)].
If applicable, any delegated activities and reporting requirements may be revoked in instances when CMS or Contracted Plan determines that the Parties have not performed satisfactorily. [42 C.F.R. § 422.504(i)(4)(ii)].
If any activities have been delegated, the performance of the Parties shall be monitored by Contracted Plan on an ongoing basis. [42 C.F.R. § 422.504(i)(4)(iii)].
If any activities have been delegated, the credentials of professionals affiliated with the Parties will either be reviewed by Contracted Plan or the credentialing process will be reviewed and approved by Contracted Plan and Contracted Plan will audit the credentialing process on an ongoing basis. [42 C.F.R. § 422.504(i)(4)(iv)].
The Parties must comply with all applicable Medicare laws, regulations, and CMS instructions. [42 C.F.R. § 422.504(i)(4)(v)].
The scope of this Agreement incorporates both the Medicare and the Medicaid population.
This Agreement is Effective either from January 1, 2014 – December 31, 2014, or contains an automatic renewal provision providing that the Agreement shall be effective during those dates.