Exhibit
10.14
Contract with Eligible Medicare
Advantage Organization Pursuant to
Sections 1851 through 1859 of the
Social Security Act for the Operation
of a Medicare Advantage Private
Fee-For-Service Plan(s)
Centers for Medicare & Medicaid
Services (hereinafter referred to as CMS)
Stone Harbor Insurance
Company
(hereinafter referred to as the MA
Organization)
CMS and the MA
Organization, an entity which has been determined to be an eligible
Medicare Advantage Organization by the Administrator of the Centers
for Medicare & Medicaid Services under 42 CFR 422.503, agree to
the following for the purposes of sections 1851 through 1859 of the
Social Security Act (hereinafter referred to as the
Act):
(NOTE:
Citations indicated in brackets are placed in the text of this
contract to note the regulatory authority for certain contract
provisions. All references to Part 422 are to 42 CFR Part
422.)
You
must check off AND initial each required Addendum type to reflect
the coverage offered under the H (or R) number associated with this
contract
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Part D
Addendum
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Employer-Only
MA-PD Addendum (800 Series)
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Employer-Only
MA Only Addendum (800 Series)
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Variances/Waivers (Provided directly to
Demonstration Organizations by CMS)
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The term of
this contract shall be from the date of signature by CMS'
authorized representative through December 31, 2007, after which
this contract may be renewed for successive one-year periods in
accordance with 42 CFR 422.505(c).
[422.505]
This contract
governs the respective rights and obligations of the parties as of
the effective date set forth above, and supersedes any prior
agreements between the MA Organization and CMS as of such date. MA
organizations offering Part D benefits also must execute an
Addendum to the Medicare Managed Care Contract Pursuant to Sections
1860D-1 through 1860D-42 of the Social Security Act for the
Operation of a Voluntary Medicare Prescription Drug Plan (hereafter
the "Part D Addendum"). For MA Organizations offering MA-PD plans,
the Part D Addendum governs the rights and obligations of the
parties relating to the provision of Part D benefits, in accordance
with its terms, as of its effective date.
Private Fee-For-Service
Plan
A. The MA
Organization agrees to operate one or more private fee-for-service
plans (as defined in 42 CFR 422.4(a)(3)), as described in its final
Plan Benefit Package (PBP) bid submission (benefit and price bid)
proposal as approved by CMS and as attested to in the Medicare
Advantage Attestation of Benefit Plan and Price, and in compliance
with the requirements of this contract and applicable Federal
statutes, regulations, and policies.
B. Except as
provided in paragraph (C) of this Article, this contract is deemed
to incorporate any changes that are required by statute to be
implemented during the term of the contract and any regulations or
policies implementing or interpreting such statutory
provisions.
C.CMS will not
implement, other than at the beginning of a calendar year,
requirements under 42 CFR Part 422 that impose a new significant
cost or burden on MA organizations or plans, unless a different
effective date is required by statute.
[422.521]
Article III
Functions To Be Performed By
Medicare Advantage Organization
1. The MA
Organization agrees to provide enrollees in each of its MA plans
the basic benefits as required under §422.101 and, to the
extent applicable, supplemental benefits under §422.102 and as
established in the MA Organization's final benefit and price bid
proposal as approved by CMS and listed in The MA Organization
Attestation of Benefit Plan and Price, which is attached to this
contract. The MA Organization agrees to provide access to such
benefits as required under subpart C in a manner consistent with
professionally recognized standards of health care and according to
the access standards stated in §422.114. The MA Organization
agrees to
provide
post-hospital extended care services, should an MA enrollee elect
such coverage, through a skilled nursing facility according to the
requirements of section 1852(1) of the Act and §422.133 . A
home skilled nursing facility is a facility in which an MA enrollee
resided at the time of admission to the hospital, a facility that
provides services through a continuing care retirement community,
or a facility in which the spouse of the enrollee is residing at
the time of the enrollee's discharge from the hospital, or
hospital, or wherever the enrollee resides immediately before
admission for extended care services. [422.133;
422.504(a)(3)] 2. The MA Organization shall authorize
benefits according to the local medical review policies (LMRPs) for
services provided in geographic areas where the LMRPs represent an
expansion of Medicare coverage policies as compared to national
Medicare coverage policies.
[422.101(b)(2)]
B. ENROLLMENT
REQUIREMENTS
1. The MA
Organization agrees to accept new enrollments, make enrollments
effective, process voluntary disenrollments, and limit involuntary
disenrollments, as provided in subpart B of part 422.
2. The MA
Organization shall comply with the provisions of §422.110
concerning prohibitions against discrimination in beneficiary
enrollment. [422.504(a)(2)]
C. BENEFICIARY
PROTECTIONS
1. The MA
Organization agrees to comply with all requirements in subpart M of
part 422 governing coverage determinations, grievances, and
appeals. [422.504(a)(7)]
2. The MA
Organization agrees to comply with the confidentiality and enrollee
record accuracy requirements in §422.118.
3.
Beneficiary Financial Protection. The MA Organization agrees
to comply with the following requirements:
(a) Each MA Organization must adopt and maintain
arrangements satisfactory to CMS to protect its enrollees from
incurring liability for payment of any fees that are the legal
obligation of the MA Organization. To meet this requirement the MA
Organization must—
(i) Ensure that all contractual (including
deemed contracts under §422.216) or other written arrangements
with providers prohibit the Organization's providers from holding
any beneficiary enrollee liable for payment of any fees that are
the legal obligation of the MA Organization; and
(ii) Indemnify the beneficiary enrollee for
payment of any fees that are the legal obligation of the MA
Organization for services furnished by providers that do not
contract, or that have not otherwise entered into an agreement with
the MA Organization, to provide services to the organization's
beneficiary enrollees. This provision does not apply to providers
operating under deemed contracts under §422.216.
[422.504(g)(l)]
(iii) Ensure that in the MA Organization's terms
and conditions of payment to hospitals, if balance billing is
imposed, the hospitals are obligated to provide notice to enrollees
of their potential liability for services where balance billing
could amount to not less than $500. This notice shall be provided
according to the requirements of§422.216(d)(2).
(b) The MA Organization must provide for
continuation of enrollee health care benefits-(i) For all
enrollees, for the duration of the contract period for which CMS
payments have been made; and
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(ii) For enrollees who are hospitalized ofi.the
date its contract with CMS terminates, or, in the event of the MA
Organization's insolvency, through the date of discharge.
[422.504(g)(2)]
(c) In meeting the requirements of this section
(C), other than the provider contract requirements specified in
paragraph (C)(3)(a) of this Article, the MA Organization may
use—
(i) Contractual arrangements;
(ii) Insurance acceptable to CMS;
(iii) Financial reserves acceptable to CMS;
or
(iv) Any other arrangement acceptable to CMS.
[422.504(g)(3)]
D. PROVIDER
PROTECTIONS
1. The MA
Organization agrees to comply with all applicable provider
requirements in 42 CFR Part 422 Subpart E, 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.
[422.504(a)(6)]
2. Prompt
Payment.
(a) The MA Organization must pay 95 percent of
"clean claims" within 30 days of receipt if they are submitted by,
or on behalf of, an enrollee of a MA PFFS plan or are for claims
for services that are not furnished under a written agreement
between the organization and the provider.
(i) The MA Organization must pay interest on
clean claims that are not paid within 30 days in accordance with
sections 1816(c)(2) and 1842(c)(2) of the Act.
(ii) All other claims from non-contracted
providers must be paid or denied within 60 calendar days from the
date of the request. [422.520(a)]
(b) Contracts, deemed contracts, or other
written agreements between the MA Organization and its providers
must contain a prompt payment provision, the terms of which are
developed and agreed to by both the MA Organization and the
relevant provider. [422.520(b)]
(c) If CMS determines, after giving notice and
opportunity for hearing, that the MA Organization has failed to
make payments in accordance with subparagraph (2)(a) of this
section, CMS may provide—
(i) For direct payment of the sums owed to
providers; and
(ii) For appropriate reduction in the amounts
that would otherwise be paid to the MA Organization, to reflect the
amounts of the direct payments and the cost of making those
payments. [422.520(c)]
(a) The MA Organization shall make payments to
providers according to the requirements of
§422.114.
(b) CMS and the MA Organization shall reach
agreement, on or before the effective date of this contract, on
provider payment methodologies, which shall include provider
payment proxies, also described as estimated Original Medicare
payment amounts.
(c) The MA Organization agrees to implement
revised provider payment schedules on the same date that such
changes are required of contractors administering the Original
Medicare benefit.
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(d) The MA Organization agrees that it ; shall
revise its provider payment schedule to reflect the requirements of
legislative or regulatory changes made during the term of this
contract. Also, the MA Organization agrees that CMS may require the
MA Organization to revise its provider payment schedule if CMS
determines that the existing schedule does not comply with the
provisions of §422.114(a)(2).
[422.114]
(e) The MA Organization agrees that it shall
establish and maintain a payment appeal system under which MA plan
providers may have their payment claims reviewed in the event that
the provider believes he was paid less than he would have been paid
under Original Medicare. Under such a system, if a provider
reasonably demonstrates that they have not received proper payment,
the MA Organization shall pay the provider the difference between
what the provider had received and what he would have received
under Original Medicare.
(f) The MA Organization agrees to make its
provider payment schedule available to the public in such a manner
as to allow providers a reasonable opportunity to be informed about
payment methodologies under the MA plan. This includes posting the
schedule on a Web site maintained by the Organization.
The MA
Organization agrees to comply with quality requirements as
described in §422.152(f).
The MA
Organization agrees to implement a compliance plan in accordance
with the requirements of §422.503(b)(4)(vi).
(422.503(b)(4)(vi)]
G. COMPLIANCE
DEEMED ON THE BASIS OF ACCREDITATION: CMS may deem the MA
Organization to have met the quality improvement requirements
of§1852(e) of the Act and §422.152, the confidentiality
and accuracy of enrollee records requirements of§1852(h) of
the Act and §422.118, the anti-discrimination requirements
of§1852(b) of the Act and §422.110, the access to
services requirements of§1852(d) of the Act and §422.112,
the advance directives requirements of§1852(i) of the Act and
§422.128, the provider participation requirements of §
1852(J) of the Act and 42 CFR Part 422, Subpart F, and the
applicable requirements described in §423.165, if the MA
Organization is fully accredited (and periodically reaccredited) by
a private, national accreditation organization approved by CMS and
the accreditation organization used the standards approved by CMS
for the purposes of assessing the MA Organization's compliance with
Medicare requirements. The provisions of §422.156 shall govern
the MA Organization's use of deemed status to meet MA program
requirements.
1. The MA
Organization agrees to provide notice based on best knowledge,
information, and belief to CMS of any integrity items related to
payments from governmental entities, both federal and state, for
healthcare or prescription drug services. These items include any
investigations, legal actions or matters subject to arbitration
brought involving the MA Organization (or MA Organization's firm if
applicable) and its subcontractors (excluding contracted network
providers), including any key management or executive staff, or any
major shareholders (5% or more), by a government agency (state or
federal) on matters relating to payments from governmental
entities, both federal and state, for healthcare and/or
prescription drug services.
In providing
the notice, the sponsor shall keep the government informed of when
the integrity item is initiated and when it is closed. Notice
should be provided of the details concerning any resolution and
monetary payments as well as any settlement agreements or corporate
integrity agreements.
2. The MA
Organization agrees to provide notice based on best knowledge,
information, and belief to CMS in the event the MA Organization or
any of its subcontractors is criminally convicted or has a civil
judgment entered against it for fraudulent activities or is
sanctioned under any Federal program involving the provision of
health care or prescription drug services.
1. The MA
Organization may not distribute any marketing materials, as defined
in 42 CFR 422.80(b) and in the Marketing Materials Guidelines for
Medicare Advantage-Prescription Drug Plans and Prescription Drug
Plans (Medicare Marketing Guidelines), unless they have been filed
with and not disapproved by CMS in accordance with §422.80.
The file and use process set out at §422.80(a)(2) must be
used, unless the MA organization notifies CMS that it will not use
this process.
2. CMS and the
MA Organization shall agree upon language setting forth the
benefits, exclusions and other language of the Plan. The MA
Organization bears full responsibility for the accuracy of its
marketing materials. CMS, in its sole discretion, may order the MA
Organization to print and distribute the agreed upon marketing
materials, in a format approved by CMS. The MA Organization must
disclose the information to each enrollee electing a plan as
outlined in 42 CFR422.111.
3. The MA
Organization agrees that any advertising material, including that
labeled promotional material, marketing materials, or supplemental
literature, shall be truthful and not misleading. All marketing
materials must include the Contract number. All membership
identification cards must include the Contract number on the front
of the card.
4. The MA
Organization must comply with the Medicare Marketing Guidelines, as
well as all applicable statutes and regulations, including and
without limitation Section 1851(h) of the Act and 42 CFR
§§422.80, 422.111 and 423.50. Failure to comply may
result in sanctions as provided in 42 CFR Part 422 Subpart
0.
CMS Payment to MA
Organization
A. The MA
Organization agrees to develop its annual benefit and price bid
proposal and submit to CMS all required information on premiums,
benefits, and cost sharing, as required under 42 CFR Part 422
Subpart F. [422.504(a)(10)]
B.
Methodology. CMS agrees to pay the MA Organization under
this contract in accordance with the provisions of section 1853 of
the Act and 42 CFR Part 422 Subpart G.
[422.504(a)(9)]
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C. Attestation
of payment data (Attachments A, B, and C).
As a condition
for receiving a monthly payment under paragraph B of this article,
and 42 CFR Part 422 Subpart G, the MA Organization agrees that its
chief executive officer (CEO), or chief financial officer (CFO), or
an individual delegated with the authority to sign on behalf of one
of these officers, and who reports directly to such officer, must
request payment under the contract on the forms attached as
Attachment A (enrollment attestation) and Attachment B (risk
adjustment data) hereto which attest to (based on best
knowledge, information and belief, as of the date specified on the
attestation form) the accuracy, completeness, and truthfulness
of the data identified on these attachments. The Medicare Advantage
Plan Attestation of Benefit Plan and Price must be signed and
attached to the executed version of this contract.
1. Attachment A
requires that the CEO, or CFO, or an individual delegated with the
authority to sign on behalf of one of these officers, and who
reports directly to such officer, must attest based on best
knowledge, information, and belief that each enrollee for whom the
MA Organization is requesting payment is validly enrolled, or was
validly enrolled during the period for which payment is requested,
in an MA plan offered by the MA Organization. The MA Organization
shall submit completed enrollment attestation forms to CMS, or its
contractor, on a monthly basis. (NOTE: The forms included as
attachments to this contract are for reference only. CMS will
provide instructions for the completion and submission of the forms
in separate documents. MA Organizations should not take any action
on the forms until appropriate CMS instructions become
available.)
2. Attachment B
requires that the CEO, or CFO, or an individual delegated with the
authority to sign on behalf of one of these officers, and who
reports directly to such officer, must attest to (based on best
knowledge, information and belief, as of the date specified on the
attestation form) that the risk adjustment data it submits to
CMS under §422.310 are accurate, complete, and truthful. The
MA Organization shall make annual attestations to this effect for
risk adjustment data on Attachment B and according to a schedule to
be published by CMS. If such risk adjustment data are generated by
a related entity, contractor, or subcontractor of an MA
Organization, such entity, contractor, or subcontractor must
similarly attest to (based on best knowledge, information, and
belief, as of the date specified on the attestation form) the
accuracy, completeness, and truthfulness of the data.
[422.504(1)]
3. The Medicare
Advantage Plan Attestation of Benefit Plan and Price (which is
attached hereto) requires that the CEO, CFO, or an individual
delegated with the authority to sign on behalf of one of these
officers, and who reports directly to such officer, must attest
(based on best knowledge, information and belief, as of the
date specified on the attestation form) that the information
and documentation comprising the bid submission proposal is
accurate, complete, and truthful and fully conforms to the Bid Form
and Plan Benefit Package requirements; and that the benefits
described in the CMS-approved proposal bid submission agree with
the benefit package the MA Organization will offer during the
period covered by the proposal bid submission. This document is
being sent separately to the MA Organization and must be signed and
attached to the executed version of this contract, and is
incorporated herein by reference.
MA Organization Relationship with
Related Entities, Contractors, and Subcontractors
A. All
references to "contracts" and "contractors" in this Article shall
include deemed contracts (where applicable) and deemed contract
providers (where applicable) as defined in
§422.216(f).
B.
Notwithstanding any relationship(s) that the MA Organization may
have with related entities, contractors, or subcontractors, the MA
Organization maintains full responsibility for adhering to and
otherwise fully complying with all terms and conditions of its
contract with CMS. [422.504(i)(l)]
C. The MA
Organization agrees to require all related entities, contractors,
or subcontractors to agree that—
1. HHS, the
Comptroller General, or their designees have the right to inspect,
evaluate, and audit any pertinent contracts, books, documents,
papers, and records of the related entity(s), contractors), or
subcontractors) involving transactions related to this contract;
and
2. HHS, the
Comptroller General, or their designees have the right to inspect,
evaluate, and audit any pertinent information for any particular
contract period for 10 years from the final date of the contract
period or from the date of completion of any audit, whichever is
later. [422.504(i)(2)]
D. The MA
Organization agrees that all contracts or written arrangements into
which the MA Organization enters with providers, related entities,
contractors, or subcontractors (first tier and downstream entities)
shall contain the following elements:
1. Enrollee
protection provisions that provide—
(a) Consistent with Article III(C), arrangements
that prohibit providers from holding an enrollee liable for payment
of any fees that are the legal obligation of the MA Organization;
and
(b) Consistent with Article III(C), provision
for the continuation of benefits.
2.
Accountability provisions that indicate that—
(a) The MA Organization oversees and is
accountable to CMS for any functions or responsibilities that are
described in these standards; and
(b) The MA Organization may only delegate
activities or functions to a provider, related entity, contractor,
or subcontractor in a manner consistent with requirements set forth
at paragraph D of this article.
3. A provision
requiring that any services or other activity performed by a
related entity, contractor or subcontractor in accordance with a
contract or written agreement between the related entity,
contractor, or subcontractor and the MA Organization will be
consistent and comply with the MA Organization's contractual
obligations to CMS. [422.504(i)(3)]
E. If any of
the MA Organization's activities or responsibilities under this
contract with CMS is delegated to other parties, the following
requirements apply to any related entity, contractor,
subcontractor, or provider:
1. Written
arrangements must specify delegated activities and reporting
responsibilities.
2. Written
arrangements must either provide for revocation of the delegation
activities and reporting requirements or specify other remedies in
instances where CMS or the MA Organization determine that such
parties have not performed satisfactorily.
3. Written
arrangements must specify that the performance of the parties is
monitored by the MA Organization on an ongoing basis.
4. Written
arrangements must specify that either—
(a) The credentials of medical professionals
affiliated with the party or parties will be either reviewed by the
MA Organization; or
(b) The provider verification process will be
reviewed and approved by the MA Organization and the MA
Organization must audit the provider verification process on an
ongoing basis. The provider verification process will consist, at a
minimum, of ensuring that providers have a state license to operate
and be eligible for payment by Medicare.
5. All
contracts or written arrangements must specify that the related
entity, contractor, or subcontractor must comply with all
applicable Medicare laws, regulations, and CMS instructions.
[422.504(i)(4)]
F. If the MA
Organization delegates selection of the providers, contractors, or
subcontractors to another organization, the MA Organization's
written arrangements with that organization must state that the MA
Organization retains the right to approve, suspend, or terminate
any such arrangement. [422.504(i)(5)]
A. MAINTENANCE
OF RECORDS
1. The MA
Organization agrees to maintain for 10 years books, records,
documents, and other
evidence of
accounting procedures and practices that—
(a) Are sufficient to do the
following:
(i) Accommodate periodic auditing of the
financial records (including data related to Medicare utilization,
costs, and computation of the benefit and price bid) of the MA
Organization.
(ii) Enable CMS to inspect or otherwise evaluate
the quality, appropriateness and timeliness of services performed
under the contract, and the facilities of the MA
Organization.
(iii) Enable CMS to audit and inspect any books
and records of the MA Organization that pertain to the ability of
the organization to bear the risk of potential financial losses, or
to services performed or determinations of amounts payable under
the contract.
(iv) Properly reflect all direct and indirect
costs claimed to have been incurred and used in the preparation of
the benefit and price bid proposal.
(v) Establish component rates of the benefit and
price bid for determining additional and supplementary
benefits.
(vi) Determine the rates utilized in setting
premiums for State insurance agency purposes and for other
government and private purchasers;
and
(b) Include at least records of the
following:
9
(i) Ownership and operation of the MA
Organization's financial, medical, and other record keeping
systems.
(ii) Financial statements for the current
contract period and ten prior periods.
(iii) Federal income tax or informational
returns for the current contract period and ten prior
periods.
(iv) Asset acquisition, lease, sale, or other
action.
(v) Agreements, contracts (including, but not
limitedto with related or unrelated prescription drug benefit
managers) and subcontracts.
(vi) Franchise, marketing, and management
agreements.
(vii) Schedules of charges for the MA
Organization's fee-for-service patients.
(viii) Matters pertaining to costs of
operations.
(ix) Amounts of income received, by source and
payment.
(x) Cash flow statements.
(xi) Any financial reports filed with other
Federal programs or State authorities.
[422.504(d)]
2. Access to facilities and records. The
MA Organization agrees to the following:
(a) The Department of Health and Human Services
(HHS), the Comptroller General, or their designee may evaluate,
through inspection or other means—
(i) The quality, appropriateness, and timeliness
of services furnished to Medicare enrollees under the
contract;
(ii) The facilities of the MA Organization;
and
(iii) The enrollment and disenrollment records
for the current contract period and ten prior periods.
(b) HHS, the Comptroller General, or their
designees may audit, evaluate, or inspect any books, contracts,
medical records, documents, papers, patient care documentation, and
other records of the MA Organization, related entity, contractor
(including deemed contract providers as defined in
§422.216(f)), subcontractor, or its transferee that pertain to
any aspect of services performed, reconciliation of benefit
liabilities, and determination of amounts payable under the
contract, or as the Secretary may deem necessary to enforce the
contract.
(c) The MA Organization agrees to make
available, for the purposes specified in section (A) of this
article, its premises, physical facilities and equipment, records
relating to its Medicare enrollees, and any additional relevant
information that CMS may require, in a manner that meets CMS record
maintenance requirements.
(d) HHS, the Comptroller General, or their
designee's right to inspect, evaluate, and audit extends through 10
years from the final date of the contract period or completion of
audit, whichever is later unless-
(i) CMS determines there is a special need to
retain a particular record or group of records for a longer period
and notifies the MA Organization at least 30 days before the normal
disposition date;
(ii) There has been a termination, dispute, or
fraud or similar fault by the MA Organization, in which case the
retention may be extended to 10 years from the date of any
resulting final resolution of the termination, dispute, or fraud or
similar fault; or
(iii) HHS, the Comptroller General, or their
designee determines that there is a reasonable possibility of
fraud, in which case they may inspect, evaluate, and audit the MA
Organization at any time. [422.504(e)]
B. REPORTING
REQUIREMENTS
1. The MA
Organization shall have an effective procedure to develop, compile,
evaluate, and report to CMS, to its enrollees, and to the general
public, at the times and in the manner that CMS requires, and while
safeguarding the confidentiality of the doctor-patient
relationship, statistics and other information as described in the
remainder of this section (B).
(422.516(a)]
2. The MA
Organization agrees to submit to CMS certified financial
information that must include the following:
(a) Such information as CMS may require
demonstrating that the organization has a fiscally sound operation,
including:
(i) The cost of its operations;
(ii) A description, submitted to CMS annually
and within 120 days of the end of the fiscal year, of significant
business transactions (as defined in §422.500) between the MA
Organization and a party in interest showing that the costs of the
transactions listed in paragraph (2)(a)(v) of this section do not
exceed the costs that would be incurred if these transactions were
with someone who is not a party in interest; or
(iii) If they do exceed, a justification that
the higher costs are consistent with prudent management and fiscal
soundness requirements.
(iv) A combined financial statement for the MA
Organization and a party in interest if either of the following
conditions is met:
(aa) Thirty-five percent or more of the costs of
operation of the MA Organization go to a party in
interest.
(bb) Thirty-five percent or more of the revenue
of a party in interest is from the MA Organization.
(422.516(b)]
(v)Requirements for combined financial
statements.
(aa) The combined financial statements required
by paragraph (2)(a)(iv) must display in separate columns the
financial information for the MA Organization and each of the
parties in interest.
(bb) Inter-entity transactions must be
eliminated in the consolidated column.
(cc) The statements must have been examined by
an independent auditor in accordance with generally accepted
accounting principles and must include appropriate opinions and
notes.
(dd) Upon written request from the MA
Organization showing good cause, CMS may waive the requirement that
the organization's combined financial statement include the
financial information required in paragraph (2)(a)(v) with respect
to a particular entity. [422.516(c)]
(vi) A description of any loans or other special
financial arrangements the MA Organization makes with contractors,
subcontractors, and related entities.
(b) Such information as CMS may require
pertaining to the disclosure of ownership and control of the MA
Organization . [422.504(f)(l)(ii)]
(c) Patterns of utilization of the MA
Organization's services.
3. The MA Organization agrees to participate in
surveys required by CMS and to submit to CMS all information that
is necessary for CMS to administer and evaluate the program and to
simultaneously establish and facilitate a process for current and
prospective beneficiaries to exercise choice in obtaining Medicare
services. This information includes, but is not limited
to:
(a) The benefits covered under the MA
plan;
(b) The MA monthly basic beneficiary premium and
MA monthly supplemental beneficiary premium, if any, for the
plan.
(c) The service area and continuation area, if
any, of each plan and the enrollment capacity of each
plan;
(d) Plan
performance indicators for the benefits under the plan including
— (i) Disenrollment rates for Medicare enrollees electing to
receive benefits through the plan for the previous 2
years;
(ii)
Information on Medicare enrollee satisfaction;
(iii) The
patterns of utilization of plan services;
(iv) The
availability, accessibility, and acceptability of the plan's
services;
(v) Information
on health outcomes and other performance measures required by
CMS;
(vi) The recent
record regarding compliance of the plan with requirements of this
part, as determined by CMS; and
(vii) Other
information determined by CMS to be necessary to assist
beneficiariesin making an informed choice among MA plans and
traditional Medicare;
(e) Information about beneficiary appeals and
their disposition;
(f) Information regarding all formal actions,
reviews, findings, or other similar actions by States, other
regulatory bodies, or any other certifying or accrediting
organization;
(g) Any other information deemed necessary by
CMS for the administration or evaluation of the Medicare program.
[422.504(f)(2)]
4. The MA
Organization agrees to provide to its enrollees and upon request,
to any individual eligible to elect an MA plan, all informational
requirements under §422.64 and, upon an enrollee's, request,
the financial disclosure information required under §422.516.
[422.504(f)(3)]
5. Reporting
and disclosure under ERISA.
(a) For any employees' health benefits plan that
includes an MA Organization in its offerings, the MA Organization
must furnish, upon request, the information the plan needs to
fulfill its reporting and disclosure obligations (with respect to
the MA Organization) under the Employee Retirement Income Security
Act of 1974 (ERISA).
(b) The MA Organization must furnish the
information to the employer or the employer's designee, or to the
plan administrator, as the term "administrator" is defined in
ERISA. [422.516(d)]
6.
Electronic communication. The MA Organization must have the
capacity to communicate with CMS electronically .
[422.504(b)]
7. Risk
Adjustment data. The MA Organization agrees to comply with the
requirements in §422.310 for submitting risk adjustment data
to CMS. [422.504(a)(8)]
Renewal of the MA
Contract
A. Renewal
of contract: In accordance with §422.505, following the
initial contract period, this contract is renewable annually only
if-
(1) The MA
Organization has not provided CMS with a notice of intention not to
renew; [422.506(a)]
12
(2) CMS and the MA Organization
reach'."agreement on the bid under 42 CFR Part 422 Subpart F; and
[422.505(d)]
(3) CMS informs the MA Organization that it
authorizes a renewal.
B. Nonrenewal
of contract
(1) Nonrenewal
by the Organization.
(a) In accordance with §422.506, the MA
Organization may elect not to renew its contract with CMS as of the
end of the term of the contract for any reason, provided it meets
the time frames for doing so set forth in subparagraphs (b) and (c)
of this paragraph.
(b) If the MA Organization does not intend to
renew its contract, it must notify—
(i) CMS, in writing, by the first Monday in June
of the year in which the contract would end, pursuant to
§422.506;
(ii) Each Medicare enrollee, at least 90 days
before the date on which the nonrenewal is effective. This notice
must include a written description of all alternatives available
for obtaining Medicare services within the service area including
alternative MA plans, Medigap options, and original Medicare and
prescription drug plans and must receive CMS approval prior to
issuance.
(iii) The general public, at least 90 days
before the end of the current calendar year, by publishing a
CMS-approved notice in one or more newspapers of general
circulation in each community located in the MA Organization's
service area.
(c) CMS may accept a nonrenewal notice submitted
after the applicable annual non-renewal notice deadline
if—
(i) The MA Organization notifies its Medicare
enrollees and the public in accordance with subparagraph (l)(b)(ii)
and (l)(b)(iii) of this section; and
(ii) Acceptance is not inconsistent with the
effective and efficient administration of the Medicare
program.
(d) If the MA Organization does not renew a
contract under subparagraph (1), CMS will not enter into an MA
contract with the Organization for 2 years from the date of
contract separation unless there are special circumstances that
warrant special consideration, as determined by CMS.
[422.506(a)]
(2) CMS decision not to renew.
(a) CMS may elect not to authorize renewal of a
contract for any of the following reasons:
(i) The MA Organization's level of enrollment,
growth in enrollment, or insufficient number of contracted
providers is determined by CMS to threaten the viability of the
organization under the MA program and or be an indicator of
beneficiary dissatisfaction with the MA plan(s) offered by the
organization.
(ii) For any of the reasons listed in
§422.510(a) [Article VIII, section (B)(l)(a) of this
contract], which would also permit CMS to terminate the
contract.
(iii) The MA Organization has committed any of
the acts in §422.752(a) that would support the imposition of
intermediate sanctions or civil money penalties under 42 CFR Part
422 Subpart 0.
(iv) The MA Organization did not submit a
benefit and price bid or the benefit and price bid was not
acceptable.
(b) Notice. CMS shall provide notice of
"its decision whether to authorize renewal of the contract as
follows:
(i) To the MA Organization by May 1 of the
contract year, except in the event of (2)(a)(iv) above, for which
notice will be sent by September 1.
(ii) To the MA Organization's Medicare enrollees
by mail at least 90 days before the end of the current calendar
year.
(iii) To the general public at least 90 days
before the end of the current calendar year, by publishing a notice
in one or more newspapers of general circulation in each community
or county located in the MA Organization's service area.
(c) Notice of appeal rights. CMS shall
give the MA Organization written notice of its right to
reconsideration of the decision not to renew in accordance with
§422.644. [422.506(b)]
Modification or Termination of the
Contract
A. Modification
or Termination of Contract by Mutual Consent
1. This
contract may be modified or terminated at any time by written
mutual consent.
(a) If the contract is modified by written
mutual consent, the MA Organization must notify its Medicare
enrollees of any changes that CMS determines are appropriate for
notification within time frames specified by CMS.
[422.508(a)(2)]
(b) If the contract is terminated by written
mutual consent, except as provided in section (A)(2) of this
Article, the MA Organization must provide notice to its Medicare
enrollees and the general public as provided in section B(2)(b)(ii)
and B(2)(b)(iii) of this Article.
[422.508(a)(l)]
2. If this
contract is terminated by written mutual consent and replaced the
day following such termination by a new MA contract, the MA
Organization is not required to provide the notice specified in
section B of this article. [422.508(b)]
B. Termination
of the Contract by CMS or the MA Organization 1. Termination by
CMS.
(a) CMS may terminate a contract for any of the
following reasons:
(i) The MA Organization has failed substantially
to carry out th
