MEDICARE ADVANTAGE ADDENDUM
The provisions of this Addendum apply to health care services rendered by Provider to Medicare Advantage (“MA”) Beneficiaries covered under a health benefits plan pursuant to a Payor’s contract (“MA Contract”) with the Centers for Medicare and Medicaid Services (“CMS”). With respect to such MA Beneficiaries, the provisions of this Addendum shall prevail over any provision in the Agreement which may conflict or appear inconsistent with any provision in this Addendum.
1.1. Compliance with Requirements of CMS. Provider shall comply, and shall require any of his/her subcontractors to comply, with any and all applicable Medicare laws, regulations, CMS instructions with respect to the provision of health care services and all other activities relating to MA Beneficiaries. Further, Provider agrees that any Covered Services provided by Provider or his/her subcontractors to MA Beneficiaries will be consistent with and will comply with the Medicare Advantage contractual obligations of the applicable Payor. Provider must have a provider agreement with CMS that permits them to provide services under original Medicare, and shall maintain such agreement throughout the term of this Agreement. Provider shall give prompt notice to MMT IPA or his/her debarment, suspension or exclusion from any government program including Medicare and Medicaid.
1.2. Exclusion from Federal Health Care Program. Provider may not employ, or subcontract with an individual, or have persons with ownership or control interests, who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare, or social services programs under Title XX of the Social Security Act, and thus have been excluded from participation in any Federal health care program under section 1128 or 1128A of the Act (or with an entity that employs or contracts with such an individual) for the provision of healthcare; utilization review; medical social work; or administrative services.
1.3. Delegation/Accountability/Oversight. If MMT IPA and/or Payor has delegated activities to Provider, then MMT IPA and/or Payor will provide the following information to Provider and Provider shall provide such information to any of his/her subcontracted entities:
1.3.1. A list of delegated activities and reporting responsibilities;
1.3.2. Arrangements for the revocation of delegated activities;
1.3.3. Notification that the performance of the contracted and subcontracted entities will be monitored by Payor;
1.3.4. Notification that the credentialing process must be approved and monitored by
1.3.5. Notification that all contracted and subcontracted entities must comply with all applicable Medicare laws, regulations and CMS instructions.
MMT IPA or Payor may revoke any delegation, including, if applicable, the delegated responsibility to meet CMS reporting requirements, and thereby terminate the MA Addendum if CMS, or MMT IPA or Payor, determines that Provider has not performed satisfactorily. Such revocation shall be consistent with the termination provisions of this MA Addendum. Performance of Provider shall be monitored by Payor on an ongoing basis as provided for in this MA Addendum. Provider further acknowledges that MMT IPA and/or Payor shall oversee and is accountable to CMS for the functions and responsibilities described in the Medicare Advantage regulatory standards and ultimately responsible to CMS for the performance of all services. Further, Provider acknowledges that MMT IPA and/or Payor may only delegate such functions and responsibilities in a manner consistent with the standards set forth under 42 CFR §422.504(i)(4).
1.4. Subdelegation. If Provider carries out any of his/her obligations or duties under the Agreement through a subcontracted arrangement, and such arrangement has been approved by MMT IPA and/or Payor if so required, such arrangement shall be in writing, shall contain: (1) an agreement by the subcontractor to comply with all of Provider’s obligations in the agreement and this MA Addendum; (2) a prompt payment provision as negotiated by Provider and the subcontractor; (3) a provision setting forth the term of the subcontract (preferably one (1) year or longer); and (4) dated signatures of all the parties to the subcontract.
1.5. Credentialing. Provider shall cooperate with MMT IPA’s and Payor’s credentialing and recredentialing process. The credentials of medical professionals affiliated with Provider will be reviewed by MMT IPA or Payor; or the credentialing process will be reviewed and approved by Payor, and Payor must audit the credentialing process on an ongoing basis, all in a manner consistent with the requirements as set forth in 42
CFR § 422.504(i)(4). To the extent that MMT IPA and/or Payor has delegated selection of the providers, contractors, or subcontractor to Provider, MMT IPA and/or Payor retains the right to approve, suspend, or terminate any such arrangement.
1.6. Policies and Procedures. Provider shall comply with all of MMT IPA’s and/or Payor's policies and procedures required for compliance with the Medicare program and any other federal or state laws, including but not limited to, the decisions, rules and regulations established by MMT IPA’s and/or Payor’s utilization review and quality assessment programs, and shall cooperate with and participate in all internal and external peer review organizations (“PRO”) review processes, independent quality review and improvement organizations activities. Medical necessity decisions regarding MA Beneficiaries will be made in compliance with CMS guidelines, and the applicable terms of the Agreement.
1.7. Consulting with Network/Participating Providers. MMT IPA shall consult with network/participating providers regarding its medical policies, quality improvement program and medical management programs and ensure that practice guidelines and utilization management guidelines: (1) are based on reasonable medical evidence or a consensus of health care professionals in the particular field; (2) consider the needs of the enrolled population; (3) are developed in consultation with participating Providers; (4) are reviewed and updated periodically; and (5) are communicated to providers and, as appropriate, to MA Beneficiaries. Payor also agrees to ensure that decisions with respect to utilization management, MA Beneficiary education, coverage of Covered Services, and other areas in which the guidelines apply are consistent with the guidelines.
1.8. CMS Notice of Discharge and Appeal Rights. Provider agrees to comply with all CMS regulations in their issuance of any and all notices required to be provided to Medicare enrollees to inform them of their rights as a patient, including their discharge and appeal rights.
1.9. Grievance/Appeal. Provider shall cooperate and comply with MMT IPA’s and/or Payor's Grievance/Appeal Process, including procedures for expedited review of initial determination and reconsideration upon the request of a MA Beneficiary in accordance with Medicare laws. Provider agrees to cooperate with MMT IPA and/or Payor in meeting its obligations regarding MA Beneficiary appeals, grievances and expedited appeals, including gathering and forwarding to MMT IPA or Payor, in a timely manner that will permit Payor to meet CMS required time frames for disposition of grievances and appeals, all information requested by MMT IPA or Payor in connection with the investigation and resolution of all appeals and grievances and compliance with appeals decisions.
1.10. Regulatory Amendment. MMT IPA may amend the Agreement or this Addendum to comply with the requirements of state and federal regulatory authorities and shall provide Provider with a copy of any such amendment and its effective date. Unless such regulatory authorities direct otherwise, the signature of Provider will not be required.
1.11. Illegal Remunerations. Both parties specifically represent and warrant, to the best of their knowledge, that activities to be performed under this Agreement are not considered illegal remunerations (including kickbacks, bribes or rebates) as defined in
42 USCA § 1320(a)-7b.
1.12. Approval of Marketing Materials. Both parties agree to comply, and to require any of their subcontractors to comply, with all applicable federal and state laws, regulations, CMS instructions, and marketing activities under this Agreement, including but not limited to, the National Marketing Guide for Medicare Managed Care Plans, and any requirements for CMS prior approval of materials.
1.13. Training, Education And Communications. In accordance with, but not limited to 42 cfr §§ 422.503(b)(4)(vi)(c)&(d) and 423.504(b)(4)(vi)(c)&(d), Provider agrees and certifies that he/she, as well as his/her employees, subcontractors, downstream entities, related entities and agents who provide services, to or for MA Beneficiaries or to or for MMT IPA or a Payor itself, shall participate in applicable compliance training and education required by applicable law, and must be made a part of the orientation for a new employee, new first tier, downstream or related entity and for all new appointments of a chief executive, manager, or governing body member. Both parties agree that MMT IPA and/or Payors or their designees may make such compliance training, education and lines of communication available to Provider in either electronic, paper or other reasonable medium. To the extent that MMT IPA and/or a Payor does not indicate that it will be documenting attendance and completion of the compliance training, education and/or lines of communication, Provider shall be responsible for documenting applicable employee’s, subcontractor’s, downstream entity’s, related entity’s and/or agent’s attendance and completion of such training. Upon notice, Provider shall provide such documentation to MMT IPA and/or Payor, unless otherwise not required by CMS regulation. In addition, the training requirement set forth herein is not required for providers or suppliers who have met the fraud, waste and abuse certification requirements through enrollment into the Medicare program, as those providers and/or suppliers are deemed to have met that portion of the fraud waste and abuse training required by CMS.
1.14. Data Reporting.
1.14.1. Data Reporting Submissions. Provider agrees to provide to MMT IPA and/or Payors all information necessary for Payors to meet their data reporting and submission obligations to CMS, including but not limited to, data necessary to characterize the context and purpose of each encounter between a Medicare Advantage Beneficiary and Provider (“Risk Adjustment Data”), and data necessary for Payor to meet its reporting obligations under 42 CFR §§
422.516 and 422.310.
1.14.2. Risk Adjustment Data. Provider’s Risk Adjustment Data shall include all
information necessary for Payor to submit such data to CMS as set forth in 42
CFR § 422.310 or any subsequent or additional regulatory provisions. If Provider fails to submit his/her Risk Adjustment Data accurately, completely and truthfully, in the format described in the 42 CFR § 422.310 or any subsequent or additional regulatory provisions, then this will result in denials and/or delays in payment of Provider’s claims.
1.14.3. Risk Adjustment Data Validation Audits. Payors and Provider are required in accordance with 42 CFR § 422.310(e) to submit a sample of medical records for MA Beneficiaries for the purpose of validation of risk adjustment data. Accordingly, Payors, or their designees, shall have the right to obtain copies of such documentation on at least an annual basis. Provider agrees to provide the requested medical records to a Payor, or Payor’s designee, within fourteen (14) calendar days from receipt of a written request. Such records shall be provided to Payors, or their designees, at no additional cost.
1.14.4. Accuracy of Risk Adjustment Data. Provider further agrees to certify, to the best of his/her knowledge, information and belief, the accuracy, completeness, and truthfulness of Provider generated Risk Adjustment Data that Payors are obligated to submit to CMS. Within thirty (30) days after the beginning of every Fiscal Year or as required by CMS while the Medicare Advantage Participation Attachment is in effect, Provider agrees to give Payors a
certification in writing, that certifies to the accuracy, completeness, and truthfulness of Provider’s Risk Adjustment Data submitted to Payor during the specified period, to the best of his/her knowledge, information and belief.
2. ACCESS TO RECORDS/FACILITIES
2.1. Maintenance of Records. Provider shall create and maintain all medical and other records and information relating to health care services in accordance with all applicable state and federal laws and shall comply with all federal and state laws regarding the confidentiality and disclosure of MA Beneficiaries’ mental health records, medical records, treatment information that identifies a particular MA Beneficiary and other health and patient information. Provider shall maintain all MA Beneficiary records in an accurate and timely manner and ensure timely access by MA Beneficiaries to the records and information that pertain to such MA Beneficiaries. Provider agrees to maintain such records and information for ten (10) years following the expiration or termination of this Agreement or completion of an audit by CMS, whichever is later.
2.2. Access to Records/Facilities.
2.2.1. Provider shall permit MMT IPA, Payor, Department of Health, United States Department of Health and Human Services, the United States Comptroller General, CMS, and any other regulatory, state or federal agency with authority over Payor or MMT IPA, timely access to audit, evaluate, inspect and copy all pertinent books, contracts, medical records, financial records, patient care documentation, encounter data and other records of Provider, or his/her first tier, downstream and related entities, including but not limited to subcontractors or transferees, that pertain to any aspect of services performed under the Agreement. Such right of audit, evaluation, inspection and copying shall extend for at least ten (10) years following the expiration or termination of this Agreement or completion of an audit by CMS, whichever is later, or such longer period of time as may be required by CMS. Further, Provider shall, upon request, provide a copy of a MA Beneficiary’s medical records or financial and statistical records relating to services rendered to MA Beneficiaries to the aforementioned organizations or agencies. For the purpose of conducting the above activities, Provider shall make available his/her premises, physical facilities and equipment, and records relating to MA Beneficiaries, including access to Provider’s computer and electronic systems and any additional relevant information that CMS may require. Provider acknowledges that failure to allow HHS, the Comptroller General or their designees the right to timely access under this section can subject Provider to a fifteen thousand dollar ($15,000) penalty for each day of failure to comply.
2.2.2. Each party agrees to abide by all federal and state laws applicable to that party regarding confidentiality and disclosure for mental health records, medical records, other health information, and enrollee information. Provider shall provide such records and information only to authorized individuals and in accordance with state and federal law, and Provider shall not release original
medical records except in accordance with federal or state laws. Both parties acknowledge that HHS, the Comptroller General or its designee have the right, to audit and/or inspect Provider’s premises to monitor and ensure compliance with the CMS requirements for maintaining the privacy and security of protected health information (PHI) and other personally identifiable information of MA Beneficiaries.
3. MA BENEFICIARY ACCESS
3.1. Nondiscrimination. Provider shall not discriminate against any patient based on race, sex, age, religion, place of residence, HIV status, source of payment, MA membership, color, sexual orientation, marital status, or any factor related to health status, including, but not limited to, a medical condition (including mental as well as physical illness), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), disability or on any other basis otherwise prohibited by state or federal law. Further, Provider shall comply with Title VI of the Civil Rights Act of 1964; the Americans with Disabilities Act; the Age Discrimination Act of 1975; other laws applicable to recipients of federal finds; and all other applicable laws, rules and regulations.
3.2. Direct Access. Provider agrees that, as mandated by state and federal law, Payors allow direct access for mammography screenings, influenza vaccinations and to women’s health specialists for routine and preventive health care services for female MA Beneficiaries. Provider agrees to comply with all of Payors’ policies with regard to direct access in such specific circumstances. No MA Beneficiary expenses shall apply to influenza or pneumococcal vaccines.
3.3. Cultural Competency. Provider shall ensure that Covered Services rendered to MA Beneficiaries, both clinical and non-clinical, are accessible to all MA Beneficiaries, including those with limited English proficiency or reading skills, with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities. Provider must provide information regarding treatment options in a cultural-competent manner, including the option of no treatment. Provider must ensure that individuals with disabilities have effective communications with participants throughout the health system in making decisions regarding treatment options.
3.4. Health Assessment. To the extent applicable, Provider agrees to cooperate with MMT IPA’s or Payor’s procedures approved by CMS to conduct an initial health assessment of all new MA Beneficiaries within ninety (90) days of the effective date of their enrollment.
3.5. Identifying Complex and Serious Medical Condition. Provider shall cooperate with MMT IPA’s or Payors’ policies for identifying MA Beneficiaries with complex or serious medical conditions for chronic care improvement initiatives; and assessment of those conditions, including medical procedures to diagnose and monitor them on an ongoing basis; and establishment and implementation of a treatment plan appropriate to those conditions, with an adequate number of direct access visits to specialists to accommodate the treatment plan. To the extent applicable, Provider agrees to assist in the development and implementation of the treatment plans and/or chronic care improvement initiatives.
3.6. Access. Provider agrees to provide Covered Services consistent with MMT IPA’s and/or Payors’: (1) standards for timely access to care and member services; (2) policies and procedures that allow for individual medical necessity determinations; and (3) policies and procedures for Provider’s consideration of MA Beneficiary input in the establishment of treatment plans. Provider shall provide access to health care services twenty-four (24) hours a day, seven (7) days a week, or at such times as Covered Services are typically provided by similar providers, to assure availability, adequacy and continuity of care to MA Beneficiaries, and by making arrangements with covering Providers to treat MA Beneficiaries when Provider is not available.
3.7. Standards of Care. All health care services shall be provided in accordance with professionally recognized standards of health care.
4. MA BENEFICIARY PROTECTIONS
4.1. Hold Harmless. Provider agrees that in no event, including but not limited to nonpayment by Payor and/or MMT IPA, insolvency of Payor and/or MMT IPA, or breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against MA Beneficiaries or persons (other than Payor) acting on an MA Beneficiary's behalf for health care services provided pursuant to the Agreement. This provision does not prohibit Provider from collecting copayments, coinsurance or deductibles as specifically provided in the evidence of coverage, or fees for non-covered health care services delivered on a fee-for-service basis to MA Beneficiaries. Nor does this Agreement prohibit Provider and an MA Beneficiary from agreeing to continue services solely at the expense of the MA Beneficiary, as long as Provider has informed the MA Beneficiary in advance, and in writing, consistent with the terms of the Agreement, that Payor may not cover or continue to cover such specific service or services. This advance notice does not apply to services not covered due to a statutory exclusion from the Medicare Advantage Program.
Provider further agrees that for MA Beneficiaries who are dual eligible enrollees for Medicare and Medicaid, that Provider will ensure they will not bill the MA Beneficiaries for cost sharing that is not the MA Beneficiaries’ responsibility and such MA Beneficiaries will not be held liable for Medicare Parts A and B cost sharing when the State is liable for the cost sharing. In addition, Provider agrees to accept Payor and/or MMT IPA’s payment as payment in full or shall bill the appropriate state source.
4.2. Continuation of Services. Provider agrees that in the event of Payor’s and/or MMT IPA’s insolvency, other cessation of operations, or termination of the Agreement, benefits to MA Beneficiaries will continue through the period for which the premium has been paid, and health care services shall continue to be rendered to MA Beneficiaries confined in an inpatient facility on the date of insolvency or other cessation of operations will continue until MA Beneficiary's medically appropriate discharge or transfer, or until the course of the health care treatment has been completed, whichever is later. Provider shall be compensated for any health care service rendered pursuant to this Section in accordance with the terms of the Agreement or as the parties shall otherwise mutually agree.
4.3. Advance Directives. Provider shall comply with all of MMT IPA’s and/or Payor’s applicable written policies and procedures to implement MA Beneficiaries’ rights to make decisions concerning their health care, including the provision of written information to all adult MA Beneficiaries regarding their rights under state and federal law to make decisions regarding their right to accept or refuse medical treatment and the right to execute an advance medical directive. Provider further agrees to document or oversee the documentation in a prominent part of the MA Beneficiaries’ medical records whether or not the MA Beneficiary has an advance directive, that Provider will follow state and federal requirements for advance directives and that Provider will provide for education of his/her staff and the community on advance directives. Provider shall not discriminate against an MA Beneficiary based on whether or not the MA Beneficiary has executed an advanced directive.
4.4. Survival of Agreement. Provider agrees that: (1) the hold harmless (Section 4.1) and continuation of care (Section 4.2) provisions shall survive the termination of the Agreement; (2) these provisions supersede any oral or written contrary agreement now existing or hereafter entered into between Provider and a MA Beneficiary or persons acting on their behalf that relates to liability for payment for, or continuation of, Covered Services provided under the terms and conditions of these clauses; and (3) any modifications, addition or deletion to these provisions shall become effective on a date no earlier than fifteen (15) days after the Administrator of CMS has received written notice of such proposed changes.
5. TERM AND TERMINATION
5.1. Notice of Termination. Notwithstanding anything contained in the Agreement to the contrary, Provider’s participation may be terminated immediately upon written notice to Provider due to: (i) Provider’s loss or suspension of licensure or certification; (ii) Provider’s sanction by Medicare or exclusion from Medicare participation; or (iii) Provider’s entering into a private contract with any Medicare beneficiary. Provider’s participation as an MA Provider may be terminated by MMT IPA upon thirty (30) days prior written notice due to failure to cooperate and comply with any of the provisions of this Addendum. If the Agreement contains any provision permitting termination of the Agreement without cause, notice of such termination shall be given by either party in accordance with the applicable provision of the Agreement, but in no case shall the notice period be less than sixty (60) days prior to the termination date. If MMT IPA decides to terminate this MA Addendum, MMT IPA shall give Ancillary Provider written notice, to the extent required under CMS regulations, of the reasons for the action, including, if relevant, the standards and the profiling data the organization used to evaluate Provider and the numbers and mix of network/participating providers MMT IPA needs. Such written notice shall also set forth Provider’s right to appeal the action and the process and timing for requesting a hearing.
5.2. Provider Termination/Suspension. If Provider is the subject of a notice of suspension, limitation or restriction on his/her authority to operate in any jurisdiction or is excluded from or voluntarily opts out of the Medicare program, Provider shall not render any services to MA Beneficiaries during such period of suspension, exclusion or nonparticipation in the Medicare program or violate the terms of such suspension, limitation, restriction or exclusion; and, further, Provider agrees to notify MMT IPA and Payor of such suspension, limitation or restriction in accordance with the Agreement. Any MA Beneficiary seeking or requiring health care services from Provider during such period of suspension, exclusion or non-participation in the Medicare program shall be referred by Payor to another Provider for such health care services.
5.3. Termination for Medicare Exclusion. Provider acknowledges that this MA Addendum shall be terminated if Provider, or a person or entity with ownership or control interest in Provider, is excluded from participation in Medicare under §1128A of the Social Security Act or from participation in any other Federal health care program.
6.1. Payment. For the provision of health care services to MA Beneficiaries, Provider shall be paid in accordance with the payment arrangement for MA Beneficiaries as set forth in the Agreement. Payment and incentive arrangements (if any) are set forth in the Agreement. MMT IPA shall ensure that any payment and incentive arrangements it has with subcontractors are specified in a written agreement.
6.2. Prompt Payment of Claims. Provider agrees to comply with the claims submission time frames as described in the Agreement. MMT IPA and/or Payor shall comply with the payment time frames as described therein and shall comply with Medicare laws with regard to untimely payment of claims for health care services rendered to MA Beneficiaries, including the penalty provisions thereof. In the event MMT IPA or a third party is delegated for claims payment, MMT IPA or such third party agrees to comply with all applicable laws regarding the timeliness of claims payment for health care services rendered hereunder, including the penalty provisions thereof. MMT IPA agrees that it or such third party shall be responsible for all interest payments due and owing as a result of MMT IPA’s failure to make such timely payments.
6.3. Federal Funds. Provider acknowledges that Payor is receiving federal funds and that payments to Provider hereunder may, to the extent reimbursed by Payor, in whole or in part, come from Federal Funds, and that Provider and Payor are subject to certain laws applicable to individuals and entities receiving federal funds, which may include but is not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR part 84; the Age Discrimination Act of 1975 as implemented by 45 CFR part 91;
the Americans with Disabilities Act; the Rehabilitation Act of 1973 and any other regulations applicable to recipients of federal funds.
7.1. Inconsistencies. In the event of an inconsistency between terms of this MA Addendum and the terms and conditions set forth in the Agreement, the terms and conditions of this MA Addendum shall govern. Except as set forth herein, all other terms and conditions of the Agreement remain in full force and effect.
7.2. Interpret According to Medicare Laws. Provider and MMT IPA intend that the terms of the Agreement and this MA Addendum as they relate to the provision of Covered Services under the Medicare Advantage program shall be interpreted in a manner consistent with applicable requirements under Medicare law.