Exhibit 10.6

 

ADDENDUM TO MEDICARE CONTRACT WITH APPROVED ENTITY

PURSUANT TO SECTIONS 1851 THROUGH 1859 OF THE SOCIAL SECURITY

ACT FOR THE OPERATION OF A MEDICARE ADVANTAGE REGIONAL

COORDINATED CARE PLAN(S)

 

I. Risk Sharing Reconciliation Submission

 

A. A Medicare Advantage (MA) Organization offering an MA regional plan shall
disclose to CMS such information as CMS determines necessary to carry out the
risk sharing reconciliation under subsection 1858(c) of the Act - including
notification to CMS of actual allowed medical costs and actual allowed medical
revenues and supporting data for the contract year under the plan by such date
and in such format as CMS specifies - in order to determine whether there are
payment adjustments for the effective contract year in accordance with Section
1858(c)(2) of the Act.

 

B. Information disclosed or obtained pursuant to this requirement may be used by
officers, employees, and contractors of CMS only for the purposes of, and to the
extent necessary in, carrying out this subsection.

 

C. The risk sharing reconciliation submission under subsection 1858(c) must be
audited by an independent Certified Public Accountant at the expense of the MA
organization, and the results of the audit plus additional information to be
specified at a later date must be submitted to CMS for our approval. Further,
CMS reserves the right conduct an independent audit of the information, at its
own expense.

 

II. Organizational and Financial Requirements

 

A. In accordance with subsection 1858(d) of the Act, an MA organization that is
offering a regional plan in a multi-state region and is not licensed in each
State in which it offers such a regional plan, may obtain a temporary waiver of
state licensure from CMS for a period of time that CMS determines appropriate
for the timely processing of the application by the State or States.

 

1. To obtain the waiver, the MA organization that is offering a multi-state
regional plan must:

 

(a) demonstrate to CMS that it has filed the necessary state licensing
application in each state in the multi-state region where a license is not held.

 

(b) notify CMS when each of the state licenses for which an application has been
filed is approved or denied.

 

2. In the case of a denied state license application, CMS may extend the
licensing waiver through the end of the plan year or as CMS determines
appropriate to provide for a transition.

 

B. An MA organization that is offering a multi-state regional plan, and which is
licensed in more than one state of that region, and which has been granted a
waiver of licensure pending approval of one or more state license applications,
must select one of the states in the region in which it is licensed in the
region, and the rules for that state will apply for

--------------------------------------------------------------------------------

Regional CCP Addendum

 

the period of the waiver to the other state or states in the region in which it
is not licensed.

 

III. Coverage of Entire MA Region

 

In accordance with paragraph 1858(a)(1) of the Act, an MA organization that is
offering a regional plan must cover the entire MA regional service area (as
defined in §422.)]. The MA organization offering a regional plan must not
segment any of it regions as described in §422.262(c)(2).

 

IV. Special Cost-Sharing Rules for MA Regional Plans

 

In accordance with paragraph 1858 (b)(2) of the Act, MA regional plans must
provide for a single deductible related to original Medicare Part A and Part B
services, if any deductible is imposed, as well as for an in-network and total
catastrophic limit on beneficiary out-of-pocket expenditures for benefits under
the original Medicare program. The MA regional plan must track the deductible
(if any) and catastrophic limits and notify members and health care providers
when the deductible (if any) or a limit has been reached as described in
§422.101(d)(4).

 

V. Election of Uniform Coverage Determination

 

A. In accordance with subsection 1858 (g) of the Act, an MA organization
offering an MA regional plan may elect to have a local coverage determination
for part of such region be the local coverage determination applied for the
entire MA region, as selected by the organization as described in §422.101(b).

 

B. An MA regional plan that applies a uniform local coverage determination for
the entire MA region must make information on the selected local coverage policy
readily available, including through the Internet, to enrollees and health care
providers as described at §422.101(b)(5) and §422.111.

 

VI. Assuring Network Adequacy and Disclosure to Enrollees

 

A. In accordance with subsection 1858(h) of the Act and §422.112(a)(1)(ii), an
MA Organization offering an MA regional plan may meet provider access to care
requirements through methods other than written agreements that establish that
access requirements have been met. The MA regional plan may rely on this
exception in seeking to designate a non-contracting hospital as an “essential
hospital” following requirements described in §422.112(c).

 

B. In accordance with subsection 1858(h), an MA regional plan must disclose to
its enrollees the process enrollees should follow to secure in-network cost
sharing when covered services are not readily available from contracted network
providers, as described in §422.111(b)(3)(ii).

 

Page 2 of 2