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Exhibit 10.1

CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-43

OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF

A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN

 

CONTRACT (S5967)

 

Between

 

Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")

 

And

 

WELLCARE PRESCRIPTION INSURANCE, INC.

(a Prescription Drug Plan Sponsor, hereinafter referred to as "PDP Sponsor")

CMS and PDP Sponsor, an entity that has been determined eligible to operate a Voluntary Medicare Prescription Drug Plan by the Administrator of CMS under 42 CFR §423.503, agree to the following for the purposes of §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Social Security Act (hereinafter referred to as "the Act").

 

 

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Article I

Voluntary Medicare Prescription Drug Plan

A. PDP Sponsor agrees to operate one or more Medicare Voluntary Prescription Drug Plans (hereinafter referred to as a "PDP"), as described in its application and related materials submitted to CMS for Medicare approval, including but not limited to all the attestations contained therein and all supplemental guidance, and in compliance with the provisions of this contract, which incorporates in its entirety the 2013 Solicitation For Applications for New Prescription Drug Plan (PDP) Sponsors released on January 10, 2012 (hereinafter collectively referred to as "the contract"). PDP Sponsor also agrees to operate in accordance with the regulations at 42 CFR Part 423 (with the exception of Subparts Q, R, and S), §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Act, and the solicitation, as well as all other applicable Federal statutes, regulations, and policies. This contract is deemed to incorporate any changes that are required by statute to be implemented during the term of this contract and any regulations or policies implementing or interpreting such statutory or regulatory provisions.

B. CMS agrees to perform its obligations to PDP Sponsor consistent with the regulations at 42 CFR Part 423 (with the exception of Subparts Q, R and S), §§1860D-1 through 1860D-43 of the Act (with the exception of §§1860D- 22(a) and 1860D-31) and the solicitation, as well as all other applicable Federal statutes, regulations, and policies.

C. CMS agrees that it will not implement, other than at the beginning of a calendar year, regulations under 42 CFR Part 423 that impose new, significant regulatory requirements on PDP Sponsor. This provision does not apply to new requirements mandated by statute.

D. If PDP Sponsor had a contract with CMS for Contract Year 2012 under the contract ID number designated above, this document is considered a renewal of the existing contract. While the terms of this document supersede the terms of the 2012 contract, the parties' execution of this contract does not extinguish or interrupt any pending obligations or actions that may have arisen under the 2012 or prior year contracts.

E. This contract is in no way intended to supersede or modify 42 CFR, Part 423. Failure to reference a regulatory requirement in this contract does not affect the applicability of such requirements to PDP Sponsor and CMS.

Article II

Functions to be Performed by PDP Sponsor

A. ENROLLMENT

1. PDP Sponsor agrees to accept new enrollments, make enrollments effective, process voluntary disenrollments, and limit involuntary disenrollments, as described in 42 CFR, Part 423, Subpart B.

2. PDP Sponsor agrees to comply with the prohibition in 42 CFR 423.104(b) on discrimination in beneficiary enrollment.

3. PDP Sponsor shall conduct Part D-related enrollment activities between October 15 and December 7 of the year prior to the contract year.

4. PDP Sponsor shall accept enrollment applications during the first 45 days of a contract year from beneficiaries who have elected to disenroll from a Medicare Advantage plan and enroll in the Medicare fee for-service program.

B. PRESCRIPTION DRUG BENEFIT

1. PDP Sponsor agrees to provide the basic prescription drug coverage as defined under 42 CFR §423.100 and, to the extent applicable, supplemental benefits as defined in 42 CFR §423.100 and in accordance with Subpart C of 42 CFR Part 423. PDP Sponsor also agrees to provide Part D benefits as described in PDP Sponsor's bid(s) approved each year by CMS (as referenced in Attachment A, to be replaced each year upon renewal of the contract to reflect the Sponsor's approved bids for the succeeding contract year).

 

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2. PDP Sponsor agrees to calculate and collect beneficiary premiums in accordance with 42 CFR §§423.286 and 423.293.

3. PDP Sponsor agrees to maintain administrative and management capabilities sufficient for the organization to organize, implement, and control the financial, marketing, benefit administration, and quality assurance activities related to the delivery of Part D services as required by 42 CFR §423.505(b)(25).

4. PDP Sponsor agrees to provide applicable beneficiaries applicable discounts on applicable drugs in accordance with the requirements of 42 CFR Part 423 Subpart W.

C. DISSEMINATION OF PLAN INFORMATION

1. PDP Sponsor agrees to provide the information required in 42 CFR §423.48.

2. PDP Sponsor acknowledges that CMS releases to the public summary reconciled Part D Payment data after the reconciliation of Part D Payments for the contract year as provided in 42 CFR §423.505(o).

3. PDP Sponsor agrees to disclose information to beneficiaries in the manner and the form specified by CMS under 42 CFR §§423.128 and 423 Subpart V-Part D Marketing Requirements, and the Medicare Marketing Guidelines for Medicare Advantage-Prescription Drug Plans (MA-PDs) and Prescription Drug Plans (PDPs).

4. PDP Sponsor certifies that all materials it submits to CMS under the File and Use Certification authority described in the Medicare Marketing Guidelines are accurate, truthful, not misleading, and consistent with CMS marketing guidelines.

D. QUALITY ASSURANCE/UTILIZATION MANAGEMENT

1. PDP Sponsor agrees to operate quality assurance, drug utilization management, and medication therapy management programs, and to support electronic prescribing in accordance with Subpart D of 42 CFR Part 423.

2. PDP Sponsor agrees to address complaints received by CMS against the Part D sponsor as required in 42 CFR §423.505(b)(22) by:

(a) Addressing and resolving complaints in the CMS complaint tracking system; and

(b) Displaying a link to the electronic complaint form on the Medicare.gov Internet Web site on the Part D plan's main Web page.

 

        3. PDP Sponsor agrees to maintain a Part D summary plan rating score of at least 3 stars as required by 42 CFR §423.505(b)(26). 

 

E. APPEALS AND GRIEVANCES

PDP Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part 423 governing coverage determinations, grievances and appeals, and formulary exceptions and the relevant provisions of Subpart U governing reopenings.

F. PAYMENT TO PDP SPONSOR

1. PDP Sponsor and CMS agree that payment under this contract will be governed by the rules in Subpart G of 42 CFR Part 423.

2. PDP Sponsor agrees that it is bound by all applicable federal laws and regulations, guidance, and authorities pertaining to claims and debt collections. In the event that the government determines that PDP Sponsor has been overpaid, PDP Sponsor agrees to return those overpaid monies back to the federal government.

G. BID SUBMISSION AND REVIEW

 

 

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If PDP Sponsor intends to participate in the Part D program for the next program year, PDP Sponsor agrees to submit the next year's bid, including all required information on premiums, benefits, and cost-sharing, by the applicable due date, as provided in Subpart F of 42 CFR Part 423 so that CMS and the Part D plan sponsor may conduct negotiations regarding the terms and conditions of the proposed bid and benefit plan renewal.

H. STATE LAW AND LICENSURE REQUIREMENTS

1. PDP Sponsor agrees to comply with State law to the extent that it is not preempted by Federal law as described in Subpart I of 42 CFR Part 423.

2. PDP Sponsor agrees that where it is operating in a State using a waiver granted pursuant to 42 CFR §423.410, such waiver shall be valid for three consecutive program years. PDP Sponsor agrees that expiration of the licensure waiver (and the failure to obtain a license from the relevant State) may be the basis for CMS deleting from PDP Sponsor's service area those PDP Regions affected by the waiver expiration. CMS may terminate or non-renew PDP Sponsor's contract where the expiration of the waiver results in PDP Sponsor not being qualified to offer a PDP plan in any PDP Region.

3. PDP Sponsor agrees that where it is operating in a State using a waiver granted pursuant to 42 CFR §423.415, such waiver shall be valid for the period that the Secretary of the Department of Health and Human Services determines is appropriate for timely processing of PDP Sponsor's license application by the State, but in no case for more than one year only, beginning on January 1 of the contract year for which CMS granted the waiver.

I. COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

1. PDP Sponsor agrees to comply with the coordination requirements with State Pharmacy Assistance Programs (SPAPs) and plans that provide other prescription drug coverage as described in Subpart J of 42 CFR Part 423.

2. PDP Sponsor agrees to comply with Medicare Secondary Payer procedures as stated in 42 CFR §423.462.

J. SERVICE AREA AND PHARMACY ACCESS

1. PDP Sponsor agrees to provide Part D benefits in the service area for which it has been approved by CMS utilizing a pharmacy network and formulary approved by CMS that meet the requirements of 42 CFR §423.120.

2. PDP Sponsor agrees to provide Part D benefits through out-of-network pharmacies according to 42 CFR §423.124.

3. PDP Sponsor agrees to provide benefits by means of point of service systems to adjudicate prescription drug claims in a timely and efficient manner in compliance with CMS standards, except when necessary to provide access in underserved areas, I/T/U pharmacies (as defined in 42 CFR §423.100), and long-term care pharmacies (as defined in 42 CFR §423.100) according to 42 CFR §423.505(b)(17).

4. PDP Sponsor agrees to contract with any pharmacy that meets PDP Sponsor's reasonable and relevant standard terms and conditions according to 42 CFR §423.505(b)(18).

K. EFFECTIVE COMPLIANCE PROGRAM/PROGRAM INTEGRITY

1. PDP Sponsor agrees that it will develop and implement an effective compliance program that applies to its Part D-related operations, consistent with 42 CFR §423.504(b)(4)(vi).

2. PDP sponsor 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 that would have been reported as part of Table A. of the Business Integrity section of the PDP application. These items include any investigations, legal actions or matters subject to arbitration brought involving the sponsor (or sponsor'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.

 

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3. PDP Sponsor agrees to provide notice based on best knowledge, information, and belief to CMS in the event the Sponsor 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.

L. LOW-INCOME SUBSIDY

PDP Sponsor agrees that it will participate in the administration of subsidies for low-income subsidy eligible individuals according to Subpart P of 42 CFR Part 423.

M. COMMUNICATION WITH CMS

PDP Sponsor agrees that it shall maintain the capacity to communicate with CMS electronically in accordance with CMS requirements.

N. BENEFICIARY FINANCIAL PROTECTIONS

PDP Sponsor agrees to afford its enrollees protection from liability for payment of fees that are the obligation of PDP Sponsor in accordance with 42 CFR §423.505(g).

O. RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES

1. PDP Sponsor agrees that it maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of this contract with CMS.

2. PDP Sponsor shall ensure that any contracts or agreements with first tier, downstream, and related entities performing functions on PDP Sponsor's behalf related to the operation of the Part D benefit are in compliance with 42 CFR §423.505(i).

3. PDP Sponsor agrees to act in accordance with 45 CFR Part 79 and agrees that it will not contract with or employ entities or individuals that are excluded by the Department of Health and Human Services, Office of the Inspector General or included on the Excluded Parties List System maintained by the General Services Administration.

P. CERTIFICATION OF DATA THAT DETERMINE PAYMENT

PDP Sponsor must provide certifications in accordance with 42 CFR §423.505(k).

Q. ENROLLMENT RELATED COSTS

PDP Sponsor agrees to payment of fees established by CMS for cost sharing of enrollment related costs in accordance with 42 CFR §423.6.

R. PDP SPONSOR REIMBURSEMENT TO PHARMACIES

1. If a PDP Sponsor uses a standard for reimbursement of pharmacies based on the cost of a drug, PDP Sponsor will update such standard not less frequently than once every 7 days, beginning with an initial update on January 1 of each year, to accurately reflect the market price of the drug.

2. PDP Sponsor will issue, mail, or otherwise transmit payment with respect to all claims submitted by pharmacies (other than pharmacies that dispense drugs by mail order only, or are located in, or contract with, a long-term care facility) within 14 days of receipt of an electronically submitted claim or within 30 days of receipt of a claim submitted otherwise.

 

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3. PDP Sponsor must ensure that a pharmacy located in, or having a contract with, a long-term care facility will have not less than 30 days (but not more than 90 days) to submit claims to PDP Sponsor for reimbursement.

Article III

Record Retention and Reporting Requirements

A. RECORD MAINTENANCE AND ACCESS

PDP Sponsor agrees to maintain records and provide access in accordance with 42 CFR §§ 423.505 (b)(10) and 423.505(i)(2).

B. GENERAL REPORTING REQUIREMENTS

PDP Sponsor agrees to submit information to CMS according to 42 CFR §§423.505(f) and 423.514, and the "Final Medicare Part D Reporting Requirements," a document issued by CMS and subject to modification each program year.

C. LICENSURE-RELATED REPORTING REQUIREMENTS

1. If PDP Sponsor is operating under a CMS-granted licensure waiver in any State, PDP Sponsor agrees to notify CMS in writing of the State's disposition of the Sponsor's license application within ten business days of the date that it receives notice of the State's action.

2. For those States where PDP Sponsor is operating under a risk-bearing license, the Sponsor agrees to provide written notice to CMS of the State's non-renewal of the Sponsor's license within ten days of receiving notice of the State's action.

3. In the event that a State regulator imposes a sanction against PDP Sponsor or requires the implementation of a corrective action plan, the Sponsor agrees to provide written notice to CMS of such sanction or corrective action requirement (including basis for the sanction and/or timeline for corrective action) within ten days of receiving notice of the State's action.

4. In the event that there is a change in the status of PDP Sponsor's risk-bearing license in any State (e.g., suspension, revocation), the Sponsor agrees to provide written notice to CMS of the change in status (including basis for the change in status and effective date) within ten days of receiving notice of the State's action.

5. If PDP Sponsor is operating a Part D benefit under a CMS-granted waiver in every State in its service area, and the Sponsor is terminating or reducing the amount of an existing letter of credit obtained for the purposes of funding projected losses, the Sponsor shall provide written notice to CMS of such action 30 days prior to its effective date. PDP Sponsor agrees that it must obtain CMS approval prior to terminating or reducing the amount of a letter of credit obtained for the purposes of funding projected losses under Appendix IV of the PDP Solicitation.

D. CMS LICENSE FOR USE OF PLAN FORMULARY

PDP Sponsor agrees to submit to CMS each plan's formulary information, including any changes to its formularies, and hereby grants to the Government, and any person or entity who might receive the formulary from the Government, a non-exclusive license to use all or any portion of the formulary for any purpose related to the administration of the Part D program, including without limitation publicly distributing, displaying, publishing or reconfiguration of the information in any medium, including www.medicare.gov, and by any electronic, print or other means of distribution.

Article IV

HIPAA Provisions

 

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A. PDP Sponsor agrees to comply with the confidentiality and enrollee record accuracy requirements specified in 42 CFR §423.136.

B. PDP Sponsor agrees to enter into a business associate agreement with the entity with which CMS has contracted to track Medicare beneficiaries' true out-of- pocket costs.

Article V

Requirements of Other Laws and Regulations

PDP Sponsor agrees to comply with (a) applicable Federal laws and regulations designed to prevent fraud, waste, and abuse, including, but not limited to applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. §§3729 et seq.), and the anti-kickback provision of § 1128B of the Act; (b) applicable HIPAA Administrative Simplification Security and Privacy rules at 45 CFR parts 160, 162, and 164; and (c) all other applicable Federal statutes and regulations.

Article VI

Contract Term and Renewal

A. TERM OF CONTRACT

This contract is effective from the date of CMS' authorized representative's signature through December 31, 2013. This contract shall be renewable for successive one-year periods thereafter according to 42 CFR §423.506.

B. QUALIFICATION TO RENEW A CONTRACT

1. In accordance with 42 CFR §423.507, PDP Sponsor will be determined qualified to renew its contract annually only if:

(a) PDP Sponsor has not provided CMS with a notice of intention not to renew in accordance with Article VII of this contract, and

(b) CMS has not provided PDP Sponsor with a notice of intention not to renew.

2. Although PDP Sponsor may be determined qualified to renew its contract under this Article, if PDP Sponsor and CMS cannot reach agreement on the bid under Subpart F of 42 CFR Part 423, no renewal takes place, and the failure to reach agreement is not subject to the appeals provisions in Subpart N of 42 CFR Part 423.

Article VII

Nonrenewal of Contract

A. NONRENEWAL BY PDP SPONSOR

1. PDP Sponsor may elect not to renew its contract with CMS, effective at the end of the term of the contract for any reason as long as PDP Sponsor provides proper notice of the decision according to the required timeframes.

2. If PDP Sponsor does not intend to renew its contract, it must notify:

(a) CMS in writing by the first Monday of June in the year in which the current contract period ends;

(b) Each Medicare enrollee, at least 90 days before the date on which the nonrenewal is effective. PDP Sponsor must provide, to enrollees, through this notice or outbound telephone calls, information on alternatives available for obtaining qualified prescription drug coverage within the PDP region, including Medicare Advantage- Prescription Drug plans, Medicare cost plans offering a Part D plan, and other PDPs, and must receive CMS approval of notices or scripts prior to their use.

 

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3. If PDP Sponsor does not renew a contract CMS cannot enter into a contract with PDP Sponsor or with an organization whose covered persons, as defined in 42 CFR §423.507(a)(4), also served as covered persons for the nonrenewing sponsor for 2 years unless there are special circumstances that warrant special consideration, as determined by CMS.

4. If PDP Sponsor does not renew a contract, it must ensure the timely transfer of any data or files in accordance with CMS instructions.

B. NONRENEWAL BY CMS

1. CMS may determine that PDP Sponsor is not qualified to renew its contract for any of the following reasons:

(a) The reasons listed in 42 CFR §423.509(a) that also permit CMS to terminate the contract.

(b) PDP Sponsor has committed any of the acts in 42 CFR §423.752 that support the imposition of intermediate sanctions or civil money penalties under 42 CFR §423.750.

2. CMS will provide notice of its decision whether PDP Sponsor is qualified to renew its contract as follows:

(a) To PDP Sponsor by August 1 of the current contract year.

(b) If CMS decides that PDP Sponsor is not qualified to renew its contract, to PDP Sponsor's Medicare enrollees by mail at least 90 days before the end of the current calendar year.

(c) CMS will provide the notice described in (B)(2)(b) of this Article where a non-renewal results because CMS and PDP Sponsor are unable to reach agreement on the bid under 42 CFR Part 423, Subpart F.

3. CMS shall give PDP Sponsor written notice of its right to appeal the decision that the sponsor is not qualified renew its contract in accordance with 42 CFR §423.642(b).

Article VIII

Modification or Termination of Contract

A. CONTRACT MODIFICATION OR TERMINATION BY MUTUAL CONSENT

1. This contract may be modified or terminated at any time by written mutual consent of the parties.

2. If this contract is terminated by mutual consent, PDP Sponsor must provide notice to its Medicare enrollees and the general public in accordance with CMS's instructions.

3. As set forth in 42 CFR §423.508, if the contract is modified by mutual consent, PDP Sponsor must notify its Medicare enrollees of any changes that CMS determines are appropriate for notification according to the process and timeframes specified by CMS.

4. If a contract is terminated under this section, PDP Sponsor must ensure the timely transfer of any data or files.

5. If a contract is terminated under this section, CMS cannot enter into a contract with PDP Sponsor or with an organization whose covered persons, as defined in 42 CFR §423.508(f), also served as covered persons for the terminating sponsor for a period of up to 2 years unless there are special circumstances that warrant special consideration, as determined by CMS.

B. TERMINATION OF CONTRACT BY CMS

CMS may terminate the contract in accordance with 42 CFR §423.509.

C. TERMINATION OF CONTRACT BY PDP SPONSOR

 

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PDP Sponsor may terminate the contract only in accordance with 42 CFR §423.510.

Article IX

Intermediate Sanctions

Consistent with Subpart O of 42 CFR Part 423, PDP Sponsor shall be subject to sanctions and civil money penalties.

Article X

Severability

Severability of the contract shall be in accordance with 42 CFR §423.504(e).

Article XI

Miscellaneous

A. DEFINITIONS

Terms not otherwise defined in this contract shall have the meaning given to such terms in 42 CFR Part 423.

B. ALTERATION TO ORIGINAL CONTRACT TERMS

PDP Sponsor agrees that it has not altered in any way the terms of the PDP contract presented for signature by CMS. PDP Sponsor agrees that any alterations to the original text that PDP Sponsor may make to this contract shall not be binding on the parties.

C. ADDITIONAL CONTRACT TERMS

PDP Sponsor agrees to include in this contract other terms and conditions in accordance with 42 CFR §423.505(j).

D. CMS APPROVAL TO BEGIN MARKETING AND ENROLLMENT ACTIVITIES

PDP Sponsor agrees that it must complete CMS operational requirements prior to receiving CMS approval to begin Part D marketing and enrollment activities. Such activities include, but are not limited to, establishing and successfully testing connectivity with CMS systems to process enrollment applications (or contracting with an entity qualified to perform such functions on PDP Sponsor's behalf) and successfully demonstrating capability to submit accurate and timely price comparison data. To establish and successfully test connectivity, PDP Sponsor must, 1) establish and test physical connectivity to the CMS data center, 2) acquire user identifications and passwords, 3) receive, store, and maintain data necessary to perform enrollments and send and receive transactions to and from CMS, and 4) check and receive transaction status information.

E. Pursuant to §13112 of the American Recovery and Reinvestment Act of 2009 (ARRA), PDP Sponsor agrees that as it implements, acquires, or upgrades its health information technology systems, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under §3004 of the Public Health Service Act, as amended by §13101 of the ARRA.

F. PDP Sponsor agrees to maintain a fiscally sound operation by at least maintaining a positive net worth (total assets exceed total liabilities) as required in 42 CFR §423.505(b)(23).

 

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In witness whereof, the parties hereby execute this contract.

This document has been electronically signed by:

FOR PDP SPONSOR

 

 

 

	
/s/ THOMAS TRAN

 

	 	 	 

 

Contracting Official Name

 

 

 

	
8/29/2012 2:09:55 PM

	 	 	 

 

Date

 

 

	WELLCARE PRESCRIPTION INSURANCE, INC.	 	
8735 Henderson Rd, Renaissance 2

Tampa, FL 33634

 

	 
	
 

Organization

	 	
 

Address

	 

 

 

FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES

 

	/s/ Cynthia Tudor    	 	
 

9/14/2012 12:31:10 PM

 

	 
	

 

Cynthia Tudor, PhD

Director

Medicare Drug Benefit

and C & D Data Group,

Center for Medicare

	 	
 

Date

	 

                                                               

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DATA USE ATTESTATION

The sponsor shall restrict its use and disclosure of Medicare data obtained from CMS information systems (listed in Attachment A) to those purposes directly related to the administration of the Medicare managed care and/or outpatient prescription drug benefits for which it has contracted with the Centers for Medicare & Medicaid Services (CMS) to administer. The sponsor shall only maintain data obtained from CMS information systems that are needed to administer the Medicare managed care and/or outpatient prescription drug benefits that it has contracted with CMS to administer. The sponsor (or its subcontractors or other related entities) may not re-use or provide other entities access to the CMS information system, or data obtained from the system, to support any line of business other than the Medicare managed care and/or outpatient prescription drug benefit for which the sponsor contracted with CMS.

The sponsor further attests that it shall limit the use of information it obtains from its Medicare plan members to those purposes directly related to the administration of such plan. The sponsor acknowledges two exceptions to this limitation. First, the sponsor may provide its Medicare members information about non-health related services after obtaining consent from the members. Second, the sponsor may provide information about health-related services without obtaining prior member consent, as long as the sponsor affords the member an opportunity to elect not to receive such information.

CMS may terminate the sponsor's access to the CMS data systems immediately upon determining that the sponsor has used its access to a data system, data obtained from such systems, or data supplied by its Medicare members beyond the scope for which CMS has authorized under this agreement. A termination of this data use agreement may result in CMS terminating the sponsor's Medicare contract(s) on the basis that it is no longer qualified as a Medicare sponsor. This agreement shall remain in effect as long as the sponsor remains a Medicare managed care organization and/or outpatient prescription drug benefit sponsor. This agreement excludes any public use files or other publicly available reports or files that CMS makes available to the general public on our website.

 

 

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Attachment A

The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency's information systems

Automated Plan Payment System (APPS)

Common Medicare Environment (CME)

Common Working File (CWF)

Coordination of Benefits Contractor (COBC)

Drug Data Processing System (DDPS)

Electronic Correspondence Referral System (ECRS)

Enrollment Database (EDB)

Financial Accounting and Control System (FACS)

Front End Risk Adjustment System (FERAS)

Health Plan Management System (HPMS), including Complaints Tracking and all other modules

HI Master Record (HIMR)

Individuals Authorized Access to CMS Computer Services (IACS)

Integrated User Interface (IUI)

Medicare Advantage Prescription Drug System (MARx)

Medicare Appeals System (MAS)

Medicare Beneficiary Database (MBD)

Payment Reconciliation System (PRS)

Premium Withholding System (PWS)

Prescription Drug Event Front End System (PDFS)

Retiree Drug System (RDS)

Risk Adjustments Processing Systems (RAPS)

 

 

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This document has been electronically signed by:

 

	
/s/ THOMAS TRAN

	 	
 

 

	 
	

 

Contracting Official Name

 

	
 

8/29/2012 2:09:55 PM

	
 

Date

WELLCARE PRESCRIPTION INSURANCE, INC.

 

	
 

Organization

8735 Henderson Rd, Renaissance 2

Tampa, FL 33634

 

 

Address

 

 

 

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SIGNATURE ATTESTATION

Contract ID: S5967

Contract Name: WELLCARE PRESCRIPTION INSURANCE, INC.

I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Health Plan Management System (HPMS) to sign the 2013 Medicare contracting documents. I also acknowledge that in accordance with the HPMS Rule of Behavior, sharing user IDs is strictly prohibited.

This document has been electronically signed by:

 

 

 

	
 

/s/ THOMAS TRAN

 

	 	
 

	 
	

 

Contracting Official Name

	 	
 

	 

                       

                                

	
8/29/2012 2:09:55 PM

 

	 	
 

	 
	

 

Date

	 	
 

	 

                 

 

	

WELLCARE PRESCRIPTION INSURANCE, INC.

 

	 	
 

	 
	

 

Organization

	 	
 

	 

          

    

 

	

8735 Henderson Rd, Renaissance 2

Tampa, FL 33634

 

	 	
 

	 
	

 

Address

	 	
 

	 

  

 S5967

  

  

  

EMPLOYER/UNION-ONLY GROUP PART D ADDENDUM TO CONTRACT WITH

APPROVED ENTITY PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-43

OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF

A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN

The Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS") and WELLCARE PRESCRIPTION INSURANCE, INC., a Prescription Drug Plan (PDP) Sponsor (hereinafter referred to as "PDP Sponsor"), agree to amend the contract S5967 governing PDP Sponsor's operation of one or more Voluntary Medicare Prescription Drug Plans, pursuant to §§1860D-1 through 1860D-43 of the Social Security Act (hereinafter referred to as "the Act"), to permit PDP Sponsor to offer employer-sponsored group prescription drug plans (as defined at 42 CFR 423.454) (hereinafter referred to in this Addendum as "employer/union-only group PDPs") in accordance with the waivers granted by CMS under §§1860D-22(b) of the Act. The terms of this Addendum shall only apply to employer/union-only group PDPs offered by PDP Sponsor exclusively to Part D eligible individuals enrolled in employment-based retiree health coverage (as defined at 42 CFR §423.882) under a contract between PDP Sponsor and the employer/union sponsor of the employment-based retiree health coverage.

This Addendum is made pursuant to Subpart K of 42 CFR Part 423.

 

 

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ARTICLE I

Voluntary Medicare Prescription Drug Plan

A. PDP Sponsor agrees to operate one or more employer/union-only group PDPs in accordance with the terms of the Medicare Prescription Drug Plan contract, as modified by this Addendum, which incorporates in its entirety the 2013 Solicitation for Applications for New Prescription Drug Plans (PDP) Sponsors (released on January 10, 2012) and any employer/union-only group waiver guidance issued by CMS (including, but is not limited to, those requirements set forth in Chapter 12 of the Prescription Drug Benefit Manual) (hereinafter "employer/union group waiver guidance”).

B. This Addendum 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 or regulatory provisions.

C. In the event of any conflict between the employer/union-only group waiver guidance issued prior to the execution of the contract and this Addendum, the provisions of this Addendum shall control. In the event of any conflict between the employer/union-only group waiver guidance issued after the execution of the contract and this Addendum, the provisions of the employer/union-only group guidance shall control.

D. This Addendum is in no way intended to supersede or modify 42 CFR Part 423 or section 1860D-1 through D-43 of the Act, except as specifically provided in applicable employer/union-only group waiver guidance and/or in this Addendum. Failure to reference a regulatory requirement in this Addendum does not affect the applicability of such requirements to PDP Sponsor and CMS.

E. The provisions of this Addendum apply to all employer/union-only group PDPs offered by PDP Sponsor under this contract number. In the event of any conflict between the provisions of this Addendum and any other provision of the contract, the terms of this Addendum shall control.

ARTICLE II

Functions To Be Performed By PDP Sponsor

A. ENROLLMENT

1. PDP Sponsor agrees to restrict enrollment in an employer/union-only group PDP to those Part D eligible individuals eligible for the employer's/union's employment-based retiree prescription drug coverage. PDP Sponsor agrees not to enroll active employees of an employer/union in its employer/union-only group PDPs.

2. PDP Sponsor will not be subject to the requirement to offer the employer/union-only group PDP to all Part D eligible beneficiaries residing in its service area as set forth in 42 CFR §423.104(b).

3. If an employer/union elects to enroll Part D eligible individuals eligible for its employer group only PDPs through a group enrollment process, PDP Sponsor will not be subject to the individual enrollment requirements set forth in 42 CFR §423.32(b). PDP Sponsor agrees that it will comply with all the requirements for group enrollment contained in CMS guidance, including those requirements contained in Chapter 3 of the Prescription Drug Benefit Manual.

B. PRESCRIPTION DRUG BENEFIT

1. Except as provided in this subsection, PDP Sponsor agrees to provide basic prescription drug coverage, as defined under 42 CFR §423.100, under any employer/union-only group PDP, in accordance with Subpart C of 42 CFR Part 423.

(a) CMS agrees that PDP Sponsor will not be subject to the actuarial equivalence requirement set forth in 42 CFR §423.104(e)(5) with respect to any employer/union-only group PDP and may provide less than the defined standard coverage between the deductible and initial coverage limit. PDP Sponsor agrees that its basic prescription drug coverage under any employer/union-only group PDP will satisfy all of the other actuarial equivalence standards set forth in 42 CFR §423.104, including but not limited to the requirement set forth in 42 CFR §423.104(e)(3) that the plan has a total or gross value that is at least equal to the total or gross value of defined standard coverage.

 

	Page 2 of 7	
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2. CMS agrees that nothing in this Addendum prevents PDP Sponsor from offering benefits in addition to basic prescription drug coverage to employers/unions. Such additional benefits offered pursuant to private agreements between PDP Sponsor and employers/unions will be considered non-Medicare Part D benefits ("non-Medicare Part D benefits"). PDP Sponsor agrees that such additional benefits may not reduce the value of basic prescription drug coverage (e.g., additional benefits cannot impose a cap that would preclude enrollees from realizing the full value of such basic prescription drug coverage).

3. PDP Sponsor agrees that enrollees of employer/union-only group PDPs shall not be charged more than the sum of his or her monthly beneficiary premium attributable to basic prescription drug coverage and 100% of the monthly beneficiary premium attributable to his or her non-Medicare Part D benefits (if any). PDP Sponsor must pass through the direct subsidy payments received from CMS to reduce the amount that the beneficiary pays (or, in those instances where the subscriber to or participant in the employer plan pays premiums on behalf of an eligible spouse or dependent, the amount the subscriber or participant pays).

4. PDP Sponsor agrees that any additional non-Medicare Part D benefits offered to an employer/union will always pay primary to the subsidies provided by CMS to low-income individuals under Subpart P of 42 CFR Part 423 (the "Low-Income Subsidy").

5. PDP Sponsor agrees enrollees of employer/union-only group PDPs will not be permitted to make payment of premiums under 42 CFR §423.293(a) through withholding from the enrollee's Social Security, Railroad Retirement Board, or Office of Personnel Management benefit payment.

6. PDP Sponsor agrees it shall obtain written agreements from each employer/union that provide that the employer/union may determine how much of an enrollee's Part D monthly beneficiary premium it will subsidize, subject to the restrictions set forth in this subsection. PDP Sponsor agrees to retain these written agreements with employers/unions, including any written agreements related to items (d) through (f), and must provide access to this documentation for inspection or audit by CMS (or its designee) in accordance with the requirements of 42 CFR §§423.504(d) and 423.505(d) and (e)

(a) The employer/union can subsidize different amounts for different classes of enrollees in the employer/union-only group PDP provided such classes are reasonable and based on objective business criteria, such as years of service, date of retirement, business location, job category, and nature of compensation (e.g., salaried v. hourly). Different classes cannot be based on eligibility for the Low Income Subsidy.

(b) The employer/union cannot vary the premium subsidy for individuals within a given class of enrollees.

(c) The employer/union cannot charge an enrollee for prescription drug coverage provided under the plan more than the sum of his or her monthly beneficiary premium attributable to basic prescription drug coverage and 100% of the monthly beneficiary premium attributable to his or her non-Medicare Part D benefits (if any). The employer/union must pass through direct subsidy payments received from CMS to reduce the amount that the beneficiary pays (or, in those instances where the subscriber to or participant in the employer plan pays premiums on behalf of an eligible spouse or dependent, the amount the subscriber or participant pays).

(d) For all enrollees eligible for the Low Income Subsidy, the low income premium subsidy amount will first be used to reduce any portion of the monthly beneficiary premium paid by the enrollee (or in those instances where the subscriber to or participant in the employer plan pays premiums on behalf of a low-income eligible spouse or dependent, the amount the subscriber or participant pays), with any remaining portion of the premium subsidy amount then applied toward the portion of any monthly beneficiary premium paid by the employer/union. However, if the sum of the enrollee's monthly premium (or the subscriber's/participant's monthly premium, if applicable) and the employer's/union's monthly premiums (i.e., total monthly premium) are less than the monthly low-income premium subsidy amount, any portion of the low-income subsidy premium amount above the total monthly premium must be returned directly to CMS. Similarly, if there is no monthly premium charged the beneficiary (or subscriber/participant, if applicable) or employer/union, the entire low-income premium subsidy amount must be returned directly to CMS and cannot be retained by PDP Sponsor, the employer/union, or the beneficiary (or the subscriber/participant, if applicable).

 

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(e) If the Part D sponsor does not or cannot directly bill an employer group's beneficiaries, CMS will permit the Part D sponsor to directly refund the amount of the low-income premium subsidy to the LIS beneficiary. This refund must meet the above requirements concerning beneficiary premium contributions; specifically, that the amount of the refund not exceed the amount of the monthly premium contribution by the enrollee and/or the employer. In addition, the sponsor must refund these amounts to the beneficiary within a reasonable time period. However, under no circumstances may this time period exceed forty five (45) days from the date that the Part D sponsor receives the low-income premium subsidy amount payment for that beneficiary from CMS.

(f) PDP Sponsor and the employer/union may agree that the employer/union will be responsible for reducing up-front the premium contribution required for enrollees eligible for the Low Income Subsidy. In those instances where the employer/union is not able to reduce up-front the premiums paid by the enrollee (or, the subscriber/participant, if applicable), PDP Sponsor and the employer/union may agree that the employer/union shall directly refund to the enrollee (or subscriber/participant, if applicable) the amount of the low-income premium subsidy up to the monthly premium contribution previously collected from the enrollee (or subscriber/participant, if applicable). The employer/union is required to complete the refund on behalf of PDP Sponsor within forty-five (45) days of the date PDP Sponsor receives from CMS the low-income premium subsidy amount payment for the low-income subsidy eligible enrollee.

(g) If the low income premium subsidy amount for which an enrollee is eligible is less than the portion of the monthly beneficiary premium paid by the enrollee (or subscriber/participant, if applicable), then the employer/union should communicate to the enrollee (or subscriber/participant) the financial consequences of the low-income subsidy eligible individual enrolling in the employer/union-only group PDP as compared to enrolling in another Part D plan with a monthly beneficiary premium equal to or below the low income premium subsidy amount.

7. For non-calendar year employer/union-only group PDPs, PDP Sponsor may determine benefits (including deductibles, out-of-pocket limits, etc.) on a non- calendar year basis subject to the following requirements:

(a) Applications, formularies, and other submissions to CMS must be submitted on a calendar year basis;

(b) The prescription drug coverage under the employer/union-only group PDP must be at least actuarially equivalent to defined standard coverage for the portion of its plan year that falls in a given calendar year. An employer/union-only group PDP will meet this standard if its prescription drug coverage is at least actuarially equivalent for the calendar year in which the plan year starts and no design change is made for the remainder of the plan year. In no event can PDP Sponsor increase during the plan year the annual out-of-pocket threshold;

(c) After an enrollee's incurred costs exceed the annual out-of-pocket threshold, the employer/union-only group PDP must provide coverage that is at least actuarially equivalent to that provided under standard prescription drug coverage; eligibility for such coverage can be determined on a plan year basis.

C. DISSEMINATION OF PLAN INFORMATION

PDP Sponsor acknowledges that CMS releases to the public summary reconciled Part D Payment data after the reconciliation of Part D Payments for the contract year as provided in 42 CFR §423.505(o). PDP Sponsor also acknowledges that CMS releases Part D retiree drug subsidy payment data for the most recently reconciled year as provided in 42 CFR §423.884(c)(3)(iii).

D. DISSEMINATION OF EMPLOYER/UNION-ONLY GROUP PLAN INFORMATION

1. Except as provided in II.C.2., CMS agrees that with respect to any employer/union-only group PDPs, PDP Sponsor will not be subject to the information requirements set forth in 42 CFR §423.48 and the prior review and approval of marketing materials and enrollment forms requirements set forth in 42 CFR §423.50. PDP Sponsor will be subject to all other dissemination requirements contained in 42 CFR §423.128 and in CMS guidance, including those requirements contained in Chapter 12 of the Prescription Drug Benefit Manual.

2. CMS agrees that the dissemination requirements set forth in 42 CFR §423.128 will not apply with respect to any employer/union-only group PDP when the employer/union is subject to alternative disclosure requirements (e.g., the Employee Retirement Income Security Act of 1974 ("ERISA")) and fully complies with such alternative requirements. PDP Sponsor agrees to comply with the requirements for this waiver contained in employer/union-only group waiver guidance, including those requirements contained in Chapter 12 of the Prescription Drug Benefit Manual.

	Page 4 of 7	
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E. PAYMENT TO PDP SPONSOR

1. Except as provided in this subsection, payment under this Addendum will be governed by the rules of Subpart G of 42 CFR Part 423.

(a) PDP Sponsor is not required to submit a Part D bid and will receive a monthly direct subsidy for each employer/union-only group PDP enrollee equal to the amount of the national average monthly bid amount, adjusted for health status (as determined under 42 CFR §423.329(b)(1)) and reduced by the base beneficiary premium for the employer/union-only group PDP, as adjusted under 42 CFR §423.286(d)(3), if applicable. The further adjustments to the base beneficiary premium contained in 42 CFR §423.286(d)(1) and (2) will not apply.

(b) PDP Sponsor agrees that the risk-sharing payment adjustment described in 42 CFR §423.336 is not applicable for any employer/union-only group PDP enrollee.

(c) PDP Sponsor will not receive monthly reinsurance payment or low-income cost-sharing subsidy amounts in the manner set forth in 42 CFR §423.329(c)(2)(i) and 42 CFR §423.329(d)(2)(i) for any employer/union-only group PDP enrollee, but instead will receive the full reinsurance and low-income cost-sharing subsidy payments following the end of year reconciliation as described in 42 CFR §423.329(c)(2)(ii) and 42 CFR §423.329(d)(2)(ii) respectively.

2. For non-calendar year plans:

(a) CMS payments will be determined on a calendar year basis;

(b) Low income subsidy payments and reconciliations will be determined based on the calendar year for which the payments are made; and

(c) PDP Sponsor acknowledges that it will not receive reinsurance payments under 42 CFR §423.329(c).

F. SERVICE AREA, FORMULARIES, AND PHARMACY ACCESS

1. CMS agrees that PDP Sponsor may offer an employer/union-only group PDP in any PDP region in which eligible enrollees reside provided PDP Sponsor has properly designated (in accordance with CMS operational requirements) its employer/union-only group service areas in CMS's Health Plan Management System (HPMS) as including those areas outside of its individual service area(s) to allow for enrollment of these beneficiaries.

2. PDP Sponsor agrees to utilize, as the formulary for any employer/union-only group PDP, a base formulary that has received approval from CMS, in accordance with CMS formulary guidance, for use in a non-group PDP offered by PDP sponsor. Except as set forth in 42 CFR §423.120(b) and sub-regulatory guidance, PDP Sponsor may not modify the approved base formulary used for any employer/union-only group PDP by removing drugs, adding additional utilization management restrictions, or increasing the cost-sharing status of a drug from the base formulary. Enhancements that are permitted to the base formulary include adding additional drugs, removing utilization management restrictions, and improving the cost-sharing status of drugs.

3. For any employer/union-only group PDP, PDP Sponsor agrees to provide Part D benefits in the plan's service area utilizing a pharmacy network and formulary that meets the requirements of 42 CFR §423.120, with the following exception: CMS agrees that the retail pharmacy access requirements set forth in 42 CFR §423.120(a)(1) will not apply when the employer/union-only group PDP's pharmacy network is sufficient to meet the needs of its enrollees throughout the employer/union-only group PDP's service area, as determined by CMS. CMS may periodically review the adequacy of the employer/union-only group PDP's pharmacy network and require the employer/union-only group PDP to expand access if CMS determines that such expansion is necessary in order to ensure that the employer/union-only group PDP's network is sufficient to meet the needs of its enrollees.

 

	Page 5 of 7	
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G. PDP SPONSOR REIMBURSEMENT TO PHARMACIES

1. If a PDP Sponsor uses a standard for reimbursement of pharmacies based on the cost of a drug, PDP Sponsor will update such standard not less frequently than once every 7 days, beginning with an initial update on January 1 of each year, to accurately reflect the market price of the drug.

2. PDP Sponsor will issue, mail, or otherwise transmit payment with respect to all claims submitted by pharmacies (other than pharmacies that dispense drugs by mail order only, or are located in, or contract with, a long-term care facility) within 14 days of receipt of an electronically submitted claim or within 30 days of receipt of a claim submitted otherwise.

3. PDP Sponsor must ensure that a pharmacy located in, or having a contract with, a long-term care facility will have not less than 30 days (but not more than 90 days) to submit claims to PDP Sponsor for reimbursement.

H. PUBLIC HEALTH SERVICE ACT

Pursuant to §13112 of the American Recovery and Reinvestment Act of 2009 (ARRA), PDP Sponsor agrees that as it implements, acquires, or upgrades its health information technology systems, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under §3004 of the Public Health Service Act, as amended by §13101 of the ARRA.

 

	Page 6 of 7	
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In witness whereof, the parties hereby execute this Addendum.

This document has been electronically signed by:

FOR THE PDP SPONSOR

 

	
/s/ THOMAS TRAN

 

	 	
 

	 
	

 

Contracting Official Name

	 	
 

	 

                       

                                

	
8/29/2012 2:09:55 PM

 

	 	
 

	 
	

 

Date

	 	
 

	 

                 

 

	

WELLCARE PRESCRIPTION INSURANCE, INC.

 

	 	

8735 Henderson Rd, Renaissance 2

Tampa, FL 33634

	 
	

 

Organization

	 	
 

Address

	 

         

FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES

 

	
/s/ Cynthia Tudor

 

	 	
9/14/2012 12:31:10 PM

	 
	

 

Cynthia Tudor, PhD

Director

Medicare Drug Benefit

and C & D Data Group,

Center for Medicare

	 	
 

Date

	 

         

                                                                    

	Page 7 of 7	
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Prescription Drug Plan Attestation of Benefit Plan 

WELLCARE PRESCRIPTION INSURANCE, INC. 

S5967 

Date: 08/29/2012

 

I attest that I have examined the Plan Benefit Packages (PBPs) identified below and that the benefits identified in the PBPs are those that the above-stated organization will make available to eligible beneficiaries in the approved service area during program year 2013. I further attest that we have reviewed the bid pricing tools (BPTs) with the certifying actuary and have determined them to be consistent with the PBPs being attested to here.

 

I attest that I have examined the employer/union-only group waiver ("800 series") PBPs identified below and that these PBPs are those that the above-stated organization will make available only to eligible employer/union- sponsored group plan beneficiaries in the approved service area during program year 2013. I further attest we have reviewed any MA bid pricing tools (BPTs) associated with these PBPs (no Part D bids are required for 2013 "800 series" PBPs) with the certifying actuary and have determined them to be consistent with any MA PBPs being attested to here.

 

I further attest that these benefits will be offered in accordance with all applicable Medicare program authorizing statutes and regulations and program guidance that CMS has issued to date and will issue during the remainder of 2012 and 2013, including but not limited to, the 2013 Call Letter, the 2013 Solicitations for New Contract Applicants, the Medicare Prescription Drug Benefit Manual, the Medicare Managed Care Manual, and the CMS memoranda issued through the Health Plan Management System (HPMS).

	
Plan 

ID

	
Segment

ID

	
Version

	
Plan Name

	
Plan Type

	
Transaction 

Type

	
Part D 

Premium

	
CMS 

Approval 

Date

	
Effective 

Date

	
138

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
33.50

	
8/20/2012

	
1/1/2013

	
139

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
30.80

	
8/20/2012

	
1/1/2013

	
140

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.40

	
8/20/2012

	
1/1/2013

	
141

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
36.00

	
8/20/2012

	
1/1/2013

	
142

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.50

	
8/20/2012

	
1/1/2013

	
143

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
38.50

	
8/20/2012

	
1/1/2013

	
144

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.00

	
8/20/2012

	
1/1/2013

	
145

	
0

	
3

	

WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
35.30

	
8/20/2012

	
1/1/2013

	
146

	
0

	
3

	

WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
35.70

	
8/20/2012

	
1/1/2013

	
147

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
31.50

	
8/20/2012

	
1/1/2013

 

	 	
 S5967

 

  

  

  

 

	
Plan

ID

	
Segment

ID

	
Version

	
Plan Name

	
Plan Type

	
Transaction

Type

	
Part D

Premium

	
CMS

Approval

Date

	
Effective

Date

	
148

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
28.50

	
08/20/2012

	
01/01/2013

	
149

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
36.10

	
08/20/2012

	
01/01/2013

	
150

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
25.70

	
08/20/2012

	
01/01/2013

	
151

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
32.40

	
08/20/2012

	
01/01/2013

	
152

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.50

	
08/20/2012

	
01/01/2013

	
154

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
33.20

	
08/20/2012

	
01/01/2013

	
155

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
36.20

	
08/20/2012

	
01/01/2013

	
156

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
28.80

	
08/20/2012

	
01/01/2013

	
157

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
36.60

	
08/20/2012

	
01/01/2013

	
158

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
36.60

	
08/20/2012

	
01/01/2013

	
159

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
30.10

	
08/20/2012

	
01/01/2013

	
160

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
35.80

	
08/20/2012

	
01/01/2013

	
161

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.70

	
08/20/2012

	
01/01/2013

	
162

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
38.80

	
08/20/2012

	
01/01/2013

	
163

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
22.10

	
08/20/2012

	
01/01/2013

	
164

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
35.30

	
08/20/2012

	
01/01/2013

	
165

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
25.40

	
08/20/2012

	
01/01/2013

	
166

	
0

	
3

 

	  WellCare

Classic

(PDP)

	  Medicare Prescription Drug Plan	
Renewal

	
25.50

	
08/20/2012

	
01/01/2013

 

	 	
 S5967

 

  

  

  

 

	
Plan

ID

	
Segment

ID

 	
Version

 	
Plan Name

 	
Plan Type

 	
Transaction

Type

 	
Part D

Premium

 	 CMS 

Approval

Date

	
Effective 

Date

	
167

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
38.70

	
08/20/2012

	
01/01/2013

	
168

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
45.20

	
08/20/2012

	
01/01/2013

	
169

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
33.00

	
08/20/2012

	
01/01/2013

	
170

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
27.70

	
08/20/2012

	
01/01/2013

	
171

	
0

	
3

	
WellCare

Classic

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
37.70

	
08/20/2012

	
01/01/2013

	
173

	
0

	
6

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
174

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
175

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.00

	
08/20/2012

	
01/01/2013

	
176

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.10

	
08/20/2012

	
01/01/2013

	
177

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
178

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.10

	
08/20/2012

	
01/01/2013

	
179

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
180

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.10

	
08/20/2012

	
01/01/2013

	
181

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

	
182

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

	
183

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
184

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

  	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

 

	 	
 S5967

 

  

  

  

	
Plan

ID

	
Segment

ID

 	  Version	  Plan Name	  Plan Type	
Transaction

Type

 	  Part D 

Premium

	
CMS

Approval

Date

	
Effective 

Date

	
185

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.00

	
08/20/2012

	
01/01/2013

	
186

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

	
187

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.00

	
08/20/2012

	
01/01/2013

	
188

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.10

	
08/20/2012

	
01/01/2013

	
189

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
190

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.00

	
08/20/2012

	
01/01/2013

	
191

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.00

	
08/20/2012

	
01/01/2013

	
192

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.00

	
08/20/2012

	
01/01/2013

	
193

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
194

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.00

	
08/20/2012

	
01/01/2013

	
195

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

	
196

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.10

	
08/20/2012

	
01/01/2013

	
197

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
34.00

	
08/20/2012

	
01/01/2013

	
198

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.00

	
08/20/2012

	
01/01/2013

	
199

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.10

	
08/20/2012

	
01/01/2013

	
200

	
0

	
3

	
WellCare

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
44.10

	
08/20/2012

	
01/01/2013

	
201

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.00

	
08/20/2012

	
01/01/2013

	 	
 S5967

 

  

  

  

 

	
Plan 

ID

	
Segment

ID

	
Version

	
Plan Name

 	
Plan Type

	
Transaction

Type

	
Part D

Premium

	
CMS

Approval

Date

	
Effective

Date

	
202

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.00

	
08/20/2012

	
01/01/2013

	
203

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
49.00

	
08/20/2012

	
01/01/2013

	
204

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
205

	
0

	
3

	
WellCare 

Extra 

(PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
39.00

	
08/20/2012

	
01/01/2013

	
803

	
0

	
1

	
PDP 

Employer 

Plan1 (PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
N/A

	
06/05/2012

	
01/01/2013

	
804

	
0

	
1

	
PDP 

Employer - 

Plan2 (PDP)

	
Medicare Prescription Drug Plan

	
Renewal

	
N/A

	
06/05/2012

	
01/01/2013

 

	 	
 S5967

 

  

  

  

 

 

	 THOMAS TRAN	 	 8/29/2012 2:09:55PM	 
	  	 	 	 
	 Contracting Official Name	 	 Date	 
	 	 	 	 
	 	 	 	 
	 	 	 8735 Henderson Rd	 
	 	 	 Ren 1	 
	 WELLCARE PRESCRIPTION INSURANCE, INC.	 	 Tampa, FL 33634	 
	 	 	 	 
	 Organization	 	 Address	 

	 	
 S5967formmacontract.htm

Back to Form 8-K

Exhibit 10.2

 

CONTRACT WITH ELIGIBLE MEDICARE ADVANTAGE (MA) ORGANIZATION

PURSUANT TO SECTIONS 1851 THROUGH 1859 OF THE SOCIAL SECURITY ACT

FOR THE OPERATION OF A MEDICARE ADVANTAGE COORDINATED CARE PLAN(S)

 

CONTRACT (__________)

 

Between

 

Centers for Medicare & Medicaid Services (hereinafter referred to as CMS)

 

and

 

[                                 ]

(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 §§ 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.)

 

 

 

 

 

 

 

 

	Page 1 of 20	 	 	 [_____]

  

  

  

 

Article I

Term of Contract

 

The term of this contract shall be from the date of signature by CMS' authorized representative through December 31, 2013, after which this contract may be renewed for successive one-year periods in accordance with 42 CFR §422.505(c) and as discussed in Paragraph A of Article VII below. [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 §§ 1860D-1 through 1860D-43 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.

Article II

Coordinated Care Plan

 

A.  The MA Organization agrees to operate one or more coordinated care plans as defined in 42 CFR §422.4(a)(1)(iii)), including at least one MA-PD plan as required under 42 CFR 422.4(c), 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 (e.g., policies as described in the Call Letter, Medicare Managed Care Manual, etc.).

 

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]

 

D.  If the MA Organization had a contract with CMS for Contract Year 2012 under the contract ID number designated above, this document is considered a renewal of the existing contract. While the terms of this document supersede the terms of the 2012 contract, the parties' execution of this contract does not extinguish or interrupt any pending obligations or actions that may have arisen under the 2012 or prior year contracts.

 

E.  This contract is in no way intended to supersede or modify 42 CFR, Part 422. Failure to reference a regulatory requirement in this contract does not affect the applicability of such requirements to the MA organization and CMS.

F.  The MA organization must comply with all applicable requirements as described in CMS regulations and guidance implementing the Medicare Improvements for Patients and Providers Act of 2008.

Article III

Functions To Be Performed By Medicare Advantage Organization

 

A.  PROVISION OF BENEFITS

 

1.  The MA Organization agrees to provide enrollees in each of its MA plans the basic benefits as required under 42 CFR §422.101 and, to the extent applicable, supplemental benefits under 42 CFR §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 Plan 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 42 CFR §422.112.

 

	Page 2 of 20	 	 	 [_____]

 

  

  

  

 

2.  The MA Organization agrees to provide post-hospital extended care services, should an MA enrollee elect such coverage, through a home skilled nursing facility, as defined at 42 CFR §422.133(b), according to the requirements of § 1852(l) of the Act and 42 CFR §422.133. [422. 133; 422.504(a)(3)]

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 42 CFR Part 422, Subpart B.

2. The MA Organization shall comply with the provisions of 42 CFR §422.110 concerning prohibitions against discrimination in beneficiary enrollment, other than in enrolling eligible beneficiaries in a CMA-approved special needs plan that exclusively enrolls special needs individuals as consistent with 42 CFR §§422.2, 422.4(a)(1)(iv) and 422.52. [422.504(a)(2)]

 

C.  BENEFICIARY PROTECTIONS

 

1.  The MA Organization agrees to comply with all requirements in 42 CFR O Part 422, Subpart M 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 42 CFR §422.118.

 

3.  Beneficiary Financial Protections. 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 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. [422.504(g)(1)]

 

(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

 

(ii)  For enrollees who are hospitalized on 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 paragraph, other than the provider contract requirements specified in subparagraph 3(a) of this paragraph, 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

 

	Page 3 of 20	 	 	 [_____]

  

  

  

 

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 claims for covered 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 §§ 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 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 paragraph, 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)]

 

E.  QUALITY IMPROVEMENT PROGRAM

 

1.  The MA Organization agrees to operate, for each plan that it offers, an ongoing quality improvement program as stated in accordance with § 1852(e) of the Social Security Act and 42 CFR §422.152.

 

2.  Chronic Care Improvement Program

 

(a)  Each MA organization must have a chronic care improvement program and must establish criteria for participation in the program. The CCIP must have a method for identifying enrollees with multiple or sufficiently severe chronic conditions who meet the criteria for participation in the program and a mechanism for monitoring enrollees' participation in the program.

 

(b)  Plans have flexibility to choose the design of their program; however, in addition to meeting the requirements specified above, the CCIP selected must be relevant to the plan's MA population. MA organizations are required to submit annual reports on their CCIP program to CMS.

 

3.  Performance Measurement and Reporting: The MA Organization shall measure performance under its MA plans using standard measures required by CMS, and report (at the organization level) its performance to CMS.  The standard measures required by CMS during the term of this contract will be uniform data collection and reporting instruments, to include the Health Plan and Employer Data Information Set (HEDIS), Consumer Assessment of Health Plan Satisfaction (CAHPS) survey, and Health Outcomes Survey (HOS). These measures will address clinical areas, including effectiveness of care, enrollee perception of care and use of services; and non-clinical areas including access to and availability of services, appeals and grievances, and organizational characteristics. [422.152(b)(1), (e)]

 

4.  Utilization Review:

 

(a)  An MA Organization for an MA coordinated care plan must use written protocols for utilization review and policies and procedures must reflect current standards of medical practice in processing requests for initial or continued authorization of services and have in effect mechanisms to detect both underutilization and over utilization of services. [422.152(b)]

 

	Page 4 of 20	 	 	 [_____]

  

  

  

 

(b)  For MA regional preferred provider organizations (RPPOs) and MA local preferred provider organizations (PPOs) that are offered by an organization that is not licensed or organized under State law as an HMOs, if the MA Organization uses written protocols for utilization review, those policies and procedures must reflect current standards of medical practice in processing requests for initial or continued authorization of services and include mechanisms to evaluate utilization of services and to inform enrollees and providers of services of the results of the evaluation. [422.152(e)]

 

5.  Information Systems:

 

(a)  The MA Organization must:

 

(i)  Maintain a health information system that collects, analyzes and integrates the data necessary to implement its quality improvement program;

 

(ii) Ensure that the information entered into the system (particularly that received from providers) is reliable and complete;

 

(iii)  Make all collected information available to CMS. [422.152(f)(1)]

 

6.  External Review: The MA Organization will comply with any requests by Quality Improvement Organizations to review the MA Organization's medical records in connection with appeals of discharges from hospitals, skilled nursing facilities, and home health agencies.

7.  The MA Organization agrees to address complaints received by CMS against the MA Organization as required in 42 CFR §422.504(a)(15) by:

(a)  Addressing and resolving complaints in the CMS complaint tracking system; and

(b)  Displaying a link to the electronic complaint form on the Medicare.gov Internet Web site on the MA plans main Web page.

 

F.  COMPLIANCE PLAN

 

The MA Organization agrees to implement a compliance plan in accordance with the requirements of 42 CFR §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 42 CFR §422.152, the confidentiality and accuracy of enrollee records requirements of §1852(h) of the Act and 42 CFR §422.118, the anti-discrimination requirements of §1852(b) of the Act and 42 CFR §422.110, the access to services requirements of §1852(d) of the Act and 42 CFR §422.112, the advance directives requirements of §1852(i) of the Act and 42 CFR §422.128, the provider participation requirements of §1852(j) of the Act and 42 CFR Part 422, Subpart E, and the applicable requirements described in 42 CFR §423.156, 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 42 CFR §422.156 shall govern the MA Organization's use of deemed status to meet MA program requirements.

 

H.  PROGRAM INTEGRITY

 

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.

 

	Page 5 of 20	 	 	 [_____]

  

  

  

 

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.

 

I.  MARKETING

1.  The MA Organization may not distribute any marketing materials, as defined in 42 CFR §422.2260 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 42 CFR §422.2264. The file and use process set out at 42 CFR §422.2262 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 CFR §422.111.

 

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 § 1851(h) of the Act and 42 CFR § 422.111, 42 CFR Part 422 Subpart V and 42 CFR Part 423 Subpart V. Failure to comply may result in sanctions as provided in 42 CFR Part 422 Subpart O.

Article IV

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 § 1853 of the Act and 42 CFR Part 422 Subpart G. [422.504(a)(9)]

 

C.  ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM PAYMENTS

The MA Organization agrees to abide by the requirements in 42 CFR §§495.200 et seq. and §1853(l) and (m) of the Act, including the fact that payment will be made directly to MA-affiliated hospitals that are certified Medicare hospitals through the Medicare FFS hospital incentive payment program.

 

D.  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), 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 hereto as Attachment A (enrollment attestation) and Attachment B (risk adjustment data) 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.

(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.)

 

	Page 6 of 20	 	 	 [_____]

  

  

  

 

1.  Attachment A 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 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.

2.  Attachment B 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 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 42 CFR §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 also 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(l)]

 

3.  The Medicare Advantage Plan Attestation of Benefit Plan and Price (an example of which is attached hereto as Attachment C) 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 proposed bid submission agree with the benefit package the MA Organization will offer during the period covered by the proposed 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. [422.504(l)]

 

Article V

MA Organization Relationship with Related Entities, Contractors, and Subcontractors

 

A.  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)(1)]

 

B.  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), contractor(s), or subcontractor(s) 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)]

 

C.  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, paragraph 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, paragraph C, provision for the continuation of benefits.

 

2.  Accountability provisions that indicate that 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.

 

	Page 7 of 20	 	 	 [_____]

  

  

  

 

3.  A provision requiring that any services or other activity performed by a first tier, downstream, or related entity in accordance with a contract will be consistent and comply with the MA Organization's contractual obligations. [422.504(i)(3)]

 

D.  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 first tier, downstream, or related entity:

 

1.  Each and every contract must specify delegated activities and reporting responsibilities.

2.  Each and every contract 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.  Each and every contract must specify that the performance of the parties is monitored by the MA Organization on an ongoing basis.

 

4.  Each and every contract 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 credentialing process will be reviewed and approved by the MA Organization and the MA Organization must audit the credentialing process on an ongoing basis.

 

5.  Each and every contract must specify that the first tier, downstream, or related entity comply with all applicable Medicare laws, regulations, and CMS instructions. [422.504(i)(4)]

 

E.  If the MA Organization delegates selection of the providers, contractors, or subcontractors to another organization, the MA Organization's contract with that organization must state that the CMS-contracting MA Organization retains the right to approve, suspend, or terminate any such arrangement. [422.504(i)(5)]

F.  As of the date of this contract and throughout its term, the MA Organization

 

1.  Agrees that any physician incentive plan it operates meets the requirements of 42 CFR §422.208, and

 

2.  Has assured that all physicians and physician groups that the MA Organization's physician incentive plan places at substantial financial risk have adequate stop-loss protection in accordance with 42 CFR §422.208(f). [422.208]

 

Article VI

Records Requirements

 

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.

 

	Page 8 of 20	 	 	 [_____]

  

  

  

 

(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:

 

(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 limited to, 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, 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 paragraph 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-

 

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(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 paragraph. [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 42 CFR §422.500) between the MA Organization and a party in interest showing that the costs of the transactions listed in subparagraph (2)(a)(v) of this paragraph 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 this subparagraph 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 this subparagraph 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. [422.516(e)]

 

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(b)  Such information as CMS may require pertaining to the disclosure of ownership and control of the MA Organization. [422.504(f)]

 

(c)  Patterns of utilization of the MA Organization's services. [422.516(a)(2)]

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 quality and 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 beneficiaries in making an informed choice among MA plans and traditional Medicare;

 

(viii)  Information about beneficiary appeals and their disposition;

 

(ix)  Information regarding all formal actions, reviews, findings, or other similar actions by States, other regulatory bodies, or any other certifying or accrediting organization;

 

(x)  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 42 CFR §422.64 and, upon an enrollee's, request, the financial disclosure information required under 42 CFR §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)]

 

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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)]

8.  The MA Organization acknowledges that CMS releases to the public summary reconciled Part D Payment data after the reconciliation of Part C and Part D Payments for the contract year as provided in 42 CFR §422.504(n) and, for Part D plan sponsors, 42 CFR §423.505(o).

Article VII

Renewal of the MA Contract

 

A.  RENEWAL OF CONTRACT

In accordance with 42 CFR §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)]

 

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 42 CFR §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 this subparagraph.

 

(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 42 CFR §422.506

 

(ii)  Each Medicare enrollee by mail, at least 90 calendar 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, MA-PD plans, Medigap options, and original Medicare and prescription drug plans and must receive CMS approval prior to issuance.

 

(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 (1)(b)(ii) of this paragraph; 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 this subparagraph, CMS will not enter into a contract with the Organization or with any organization whose covered persons, as defined at 42 CFR §422.506(a)(5), also served as covered persons for the non-renewing MA Organization for 2 years unless there are special circumstances that warrant special consideration, as determined by CMS. [422.506(a)]

 

2.  CMS decision not to renew.

 

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(a)   CMS may elect not to authorize renewal of a contract for any of the following reasons:

 

(i)  For any of the reasons listed in 42 CFR §422.510(a) which would also permit CMS to terminate the contract.

 

(ii)  The MA Organization has committed any of the acts in 42 CFR §422.752(a) that would support the imposition of intermediate sanctions or civil money penalties under 42 CFR Part 422 Subpart O.

 

(iii)  The MA Organization did not submit a benefit and price bid or the benefit and price bid was not acceptable [422.505(d)]

 

(b)   Notice. CMS shall provide notice of its decision whether to authorize renewal of the contract as follows:

(i)  To the MA Organization by August 1 of the contract year, except in the event described in subparagraph (2)(a)(iii) of this paragraph, 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.

 

(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 42 CFR §422.644. [422.506(b)]

 

Article VIII

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 subparagraph 2 of this paragraph, the MA Organization must provide notice to its Medicare enrollees and the general public as provided in paragraph B, subparagraph 2(b) of this Article. [422.508(a)(1)]

 

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 paragraph 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 at any time terminate a contract if CMS determines that the MA Organization meets any of the following:

 

(i)  has failed substantially to carry out the terms of its contract with CMS.

 

(ii)  is carrying out its contract in a manner that is inconsistent with the efficient and effective implementation of 42 CFR Part 422.

 

(iii)  no longer substantially meets the applicable conditions of 42CFR Part 422.

 

(iv)  based on creditable evidence, has committed or participated in false, fraudulent or abusive activities affecting the Medicare, Medicaid or other State or Federal health care program, including submission of false or fraudulent data.

 

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(v)  experiences financial difficulties so severe that its ability to make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its enrollees, or otherwise fails to make services available to the extent that such a risk to health exists.

 

(vi)  substantially fails to comply with the requirements in 42 CFR Part 422 Subpart M relating to grievances and appeals.

 

(vii)  fails to provide CMS with valid risk adjustment data as required under 42 CFR §§422.310 and 423.329(b)(3).

 

(viii)  fails to implement an acceptable quality improvement program as required under 42 CFR Part 422 Subpart D.

(ix)  substantially fails to comply with the prompt payment requirements in 42 CFR §422.520.

 

(x)  substantially fails to comply with the service access requirements in 42 CFR §422.112.

 

(xi)  fails to comply with the requirements of 42 CFR §422.208 regarding physician incentive plans.

 

(xii)  substantially fails to comply with the marketing requirements in 42 CFR Part 422 Subpart V.

 

(b)  Notice. If CMS decides to terminate a contract for reasons other than the grounds specified in subparagraph 1 (a) of this paragraph, it will give notice of the termination as follows:

 

(i)  CMS will notify the MA Organization in writing 90 days before the intended date of the termination.

 

(ii)  The MA Organization will notify its Medicare enrollees of the termination by mail at least 30 days before the effective date of the termination.

 

(iii)  The MA Organization will notify the general public of the termination at least 30 days before the effective date of the termination 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)  Expedited termination of contract by CMS.

 

(i)  For terminations based on violations prescribed in subparagraph 1(a)(iv) or (v) of this paragraph, CMS will notify the MA Organization in writing that its contract has been terminated on a date specified by CMS. If a termination is effective in the middle of a month, CMS has the right to recover the prorated share of the capitation payments made to the MA Organization covering the period of the month following the contract termination.

 

(ii)  CMS will notify the MA Organization's Medicare enrollees in writing of CMS' decision to terminate the MA Organization's contract. This notice will occur no later than 30 days after CMS notifies the plan of its decision to terminate this contract. CMS will simultaneously inform the Medicare enrollees of alternative options for obtaining Medicare services, including alternative MA Organizations in a similar geographic area and original Medicare.

 

(iii)  CMS will notify the general public of the termination no later than 30 days after notifying the MA Organization of CMS' decision to terminate this contract. This notice will be published in one or more newspapers of general circulation in each community or county located in the MA Organization's service area.

 

(d)  Corrective action plan

 

(i)  General. Before providing a notice of intent to terminate a contract for reasons other than the grounds specified in subparagraph 1(a)(iv) or (v) of this paragraph, CMS will provide the MA Organization with notice specifying the MA Organization's deficiencies and a reasonable opportunity of at least 30 calendar days to develop and implement an approved corrective action plan to correct the deficiencies that are the basis of the proposed termination.

 

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(ii)  Exceptions. If a contract is terminated under subparagraph 1(a)(iv) or (v) of this paragraph, the MA Organization will not be provided with the opportunity to develop and implement a corrective action plan.

 

(e)  Appeal rights. If CMS decides to terminate this contract, it will send written notice to the MA Organization informing it of its termination appeal rights in accordance with 42 CFR Part 422 Subpart N. [422.510(d)]

 

2.  Termination by the MA Organization

 

(a)  Cause for termination.  The MA Organization may terminate this contract if CMS fails to substantially carry out the terms of the contract.

 

(b)  Notice. The MA Organization must give advance notice as follows:

(i)  To CMS, at least 90 days before the intended date of termination. This notice must specify the reasons why the MA Organization is requesting contract termination.

 

(ii)  To its Medicare enrollees, at least 60 days before the termination effective date. This notice must include a written description of alternatives available for obtaining Medicare services within the service area, including alternative MA and MA-PD plans, PDP plans, Medigap options, and original Medicare and must receive CMS approval.

 

(iii)  To the general public at least 60 days before the termination effective date by publishing a CMS-approved notice in one or more newspapers of general circulation in each community or county located in the MA Organization's geographic area.

 

(c)  Effective date of termination. The effective date of the termination will be determined by CMS and will be at least 90 days after the date CMS receives the MA Organization's notice of intent to terminate.

 

(d)  CMS' liability. CMS' liability for payment to the MA Organization ends as of the first day of the month after the last month for which the contract is in effect, but CMS shall make payments for amounts owed prior to termination but not yet paid.

 

(e)  Effect of termination by the organization. CMS will not enter into an agreement with the MA Organization or with an organization whose covered persons, as defined in 42 CFR §422.512(e)(2), also served as covered persons for the terminating MA Organization for a period of two years from the date the Organization has terminated this contract, unless there are circumstances that warrant special consideration, as determined by CMS. [422.512]

 

Article IX

Requirements of Other Laws and Regulations

 

A.  The MA Organization agrees to comply with —

 

1.  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 (31 USC §§3729 et seq.) , and the anti-kickback statute (§ 1128B(b) of the Act): and

 

2.  HIPAA administrative simplification rules at 45 CFR Parts 160, 162, and 164. [422.504(h)]

 

B.  Pursuant to § 13112 of the American Recovery and Reinvestment Act of 2009 (ARRA), the MA Organization agrees that as it implements, acquires, or upgrades its health information technology systems, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under § 3004 of the Public Health Service Act, as amended by § 13101 of the ARRA.

 

C.  The MA Organization maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with CMS, notwithstanding any relationship(s) that the MA Organization may have with related entities, contractors, or subcontractors. [422.504(i)]

 

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D.  In the event that any provision of this contract conflicts with the provisions of any statute or regulation applicable to an MA Organization, the provisions of the statute or regulation shall have full force and effect.

 

Article X

Severability

 

The MA Organization agrees that, upon CMS' request, this contract will be amended to exclude any MA plan or State-licensed entity specified by CMS, and a separate contract for any such excluded plan or entity will be deemed to be in place when such a request is made. [422.504(k)]

 

Article XI

Miscellaneous

 

A.  DEFINITIONS

Terms not otherwise defined in this contract shall have the meaning given to such terms in 42 CFR Part 422.

B.  ALTERATION TO ORIGINAL CONTRACT TERMS

The MA Organization agrees that it has not altered in any way the terms of this contract presented for signature by CMS. The MA Organization agrees that any alterations to the original text the MA Organization may make to this contract shall not be binding on the parties.

 

C.  APPROVAL TO BEGIN MARKETING AND ENROLLMENT

The MA Organization agrees that it must complete CMS operational requirements prior to receiving CMS approval to begin Part C marketing and enrollment activities. Such activities include, but are not limited to, establishing and successfully testing connectivity with CMS systems to process enrollment applications (or contracting with an entity qualified to perform such functions on the MA Organization's Sponsor's behalf) and successfully demonstrating capability to submit accurate and timely price comparison data. To establish and successfully test connectivity, the MA Organization must, 1) establish and test physical connectivity to the CMS data center, 2) acquire user identifications and passwords, 3) receive, store, and maintain data necessary to perform enrollments and send and receive transactions to and from CMS, and 4) check and receive transaction status information.

D. MA Organization agrees to maintain a fiscally sound operation by at least maintaining a positive net worth (total assets exceed total liabilities) as required in 42 CFR § 422.504(a)(14).

E. MA Organization agrees to maintain administrative and management capabilities sufficient for the organization to organize, implement, and control the financial, marketing, benefit administration, and quality improvement activities related to the delivery of Part C services as required by 42 CFR §422.504(a)(17).

F. MA Organization agrees to maintain a Part C summary plan rating score of at least 3 stars as required by 42 CFR §422.504(a)(18).

 

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ATTACHMENT A

 

ATTESTATION OF ENROLLMENT INFORMATION

RELATING TO CMS PAYMENT

TO A MEDICARE ADVANTAGE ORGANIZATION

 

Pursuant to the contract(s) between the Centers for Medicare & Medicaid Services (CMS) and (INSERT NAME OF MA ORGANIZATION), hereafter referred to as the MA Organization, governing the operation of the following Medicare Advantage plans (INSERT PLAN IDENTIFICATION NUMBERS HERE), the MA Organization hereby requests payment under the contract, and in doing so, makes the following attestation concerning CMS payments to the MA Organization. The MA Organization acknowledges that the information described below directly affects the calculation of CMS payments to the MA Organization and that misrepresentations to CMS about the accuracy of such information may result in Federal civil action and/or criminal prosecution. This attestation shall not be considered a waiver of the MA Organization's right to seek payment adjustments from CMS based on information or data which does not become available until after the date the MA Organization submits this attestation.

 

1.  The MA Organization has reported to CMS for the month of (INDICATE MONTH AND YEAR) all new enrollments, disenrollments, and appropriate changes in enrollees' status with respect to the above-stated MA plans. Based on best knowledge, information, and belief as of the date indicated below, all information submitted to CMS in this report is accurate, complete, and truthful.

 

2.  The MA Organization has reviewed the CMS monthly membership report and reply listing for the month of (INDICATE MONTH AND YEAR) for the above-stated MA plans and has reported to CMS any discrepancies between the report and the MA Organization's records. For those portions of the monthly membership report and the reply listing to which the MA Organization raises no objection, the MA Organization, through the certifying CEO/CFO, will be deemed to have attested, based on best knowledge, information, and belief as of the date indicated below, to its accuracy, completeness, and truthfulness.

 

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ATTACHMENT B

 

ATTESTATION OF RISK ADJUSTMENT DATA INFORMATION RELATING TO

CMS PAYMENT TO A MEDICARE ADVANTAGE ORGANIZATION

 

Pursuant to the contract(s) between the Centers for Medicare & Medicaid Services (CMS) and (INSERT NAME OF MA ORGANIZATION), hereafter referred to as the MA Organization, governing the operation of the following Medicare Advantage plans (INSERT PLAN IDENTIFICATION NUMBERS HERE), the MA Organization hereby requests payment under the contract, and in doing so, makes the following attestation concerning CMS payments to the MA Organization. The MA Organization acknowledges that the information described below directly affects the calculation of CMS payments to the MA Organization or additional benefit obligations of the MA Organization and that misrepresentations to CMS about the accuracy of such information may result in Federal civil action and/or criminal prosecution.

 

The MA Organization has reported to CMS during the period of (INDICATE DATES) all (INDICATE TYPE - DIAGNOSIS/ENCOUNTER) risk adjustment data available to the MA Organization with respect to the above-stated MA plans. Based on best knowledge, information, and belief as of the date indicated below, all information submitted to CMS in this report is accurate, complete, and truthful.

 

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ATTACHMENT C - Medicare Advantage Plan Attestation of Benefit Plan and Price

 

 

 

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In witness whereof, the parties hereby execute this contract.

 

This document has been electronically signed by:

 

FOR THE MA ORGANIZATION

 

/s/ THOMAS TRAN

	  	  

 

Contracting Official Name

 

8/29/2012

	  	  

 

Date

 

 

	
 [                      ]

 

	  	
 [                      ]

	  
	
 

Organization

	  	
 Address

	  

 

 

FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES

 

	
/s/ Danielle R. Moon    

 

	     	9/14/2012	 
	
 

Danielle R. Moon, J.D., M.P.A.

Director

Medicare Drug and Health

Plan Contract Administration Group,

Center for Medicare

 

 

	 	
 

Date

	 

 

 

 

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ADDENDUM TO MEDICARE MANAGED CARE CONTRACT PURSUANT TO

SECTIONS 1860D-1 THROUGH 1860D-43 OF THE SOCIAL SECURITY ACT FOR

THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN

 

The Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS") and [__________________], a Medicare managed care organization (hereinafter referred to as MA-PD Sponsor) agree to amend the contract [_______] governing MA-PD Sponsor's operation of a Part C plan described in § 1851(a)(2)(A) of the Social Security Act (hereinafter referred to as "the Act") or a Medicare cost plan to include this addendum under which MA-PD Sponsor shall operate a Voluntary Medicare Prescription Drug Plan pursuant to §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Act.

 

This addendum is made pursuant to Subpart L of 42 CFR Part 417 (in the case of cost plan sponsors offering a Part D benefit) and Subpart K of 42 CFR Part 422 (in the case of an MA-PD Sponsor offering a Part C plan).

 

NOTE: For purposes of this addendum, unless otherwise noted, reference to an "MA-PD Sponsor" or "MA-PD Plan" is deemed to include a cost plan sponsor or a MA private fee-for-service contractor offering a Part D benefit.

 

 

	Page 1 of 9	 	 	 [_____]

 

 

  

  

Article I

Voluntary Medicare Prescription Drug Benefit

 

A.  MA-PD Sponsor agrees to operate one or more Medicare Voluntary Prescription Drug Plans as described in its application and related materials submitted to CMS for Medicare approval, including but not limited to all the attestations contained therein and all supplemental guidance, and in compliance with the provisions of this addendum, which incorporates in its entirety the 2013 Solicitation For Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors, released on January 10, 2012 [applicable to Medicare Part C contractors] or the 2013 Solicitation for Applications for New Cost Plan Sponsors, released on January 10, 2012 [applicable to Medicare cost plan contractors] (hereinafter collectively referred to as "the addendum"). MA-PD Sponsor also agrees to operate in accordance with the regulations at 42 CFR Part 423 (with the exception of Subparts Q, R, and S), §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Act, and the applicable solicitation identified above, as well as all other applicable Federal statutes, regulations, and policies. This addendum is deemed to incorporate any changes that are required by statute to be implemented during the term of this contract and any regulations or policies implementing or interpreting such statutory or regulatory provisions.

 

B.  CMS agrees to perform its obligations to MA-PD Sponsor consistent with the regulations at 42 CFR Part423 (with the exception of Subparts Q, R, and S), §§1860D-1 through 1860D-43 (with the exception of §§1860D-22(a) and 1860D-31) of the Act, and the applicable solicitation, as well as all other applicable Federal statutes, regulations, and policies.

 

C.  CMS agrees that it will not implement, other than at the beginning of a calendar year, regulations under 42 CFR Part 423 that impose new, significant regulatory requirements on MA-PD Sponsor. This provision does not apply to new requirements mandated by statute.

 

D.  If MA-PD Sponsor had an MA-PD Addendum with CMS for Contract Year 2012 under the contract ID number designated above, this document is considered a renewal of the existing addendum. While the terms of this document supersede the terms of the 2012 addendum, the parties' execution of this contract does not extinguish or interrupt any pending obligations or actions that may have arisen under the 2012 or prior year addendums.

E.  This addendum is in no way intended to supersede or modify 42 CFR, Parts 417, 422 or 423. Failure to reference a regulatory requirement in this addendum does not affect the applicability of such requirements to MAPD Sponsor and CMS.

 

Article II

Functions to be Performed by MA-PD Sponsor

 

	
A.

	
ENROLLMENT

 

1.  MA-PD Sponsor agrees to enroll in its MA-PD plan only Part D-eligible beneficiaries as they are defined in 42 CFR §423.30(a) and who have elected to enroll in MA-PD Sponsor's Part C or §1876 benefit.

 

2.  If MA-PD Sponsor is a cost plan sponsor, MA-PD Sponsor acknowledges that its §1876 plan enrollees are not required to elect enrollment in its Part D plan.

 

	
B.

	
PRESCRIPTION DRUG BENEFIT

 

1.  MA-PD Sponsor agrees to provide the required prescription drug coverage as defined under 42 CFR §423.100 and, to the extent applicable, supplemental benefits as defined in 42 CFR §423.100 and in accordance with Subpart C of 42 CFR Part 423. MA-PD Sponsor also agrees to provide Part D benefits as described in MA-PD Sponsor's Part D bid(s) approved each year by CMS (and in the Attestation of Benefit Plan and Price, attached hereto).

 

2.  MA-PD Sponsor agrees to calculate and collect beneficiary Part D premiums in accordance with 42 CFR §§423.286 and 423.293.

 

3.  If MA-PD Sponsor is a cost plan sponsor, it acknowledges that its Part D benefit is offered as an optional supplemental service in accordance with 42 CFR §417.440(b)(2)(ii).

 

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4.  PDP Sponsor agrees to maintain administrative and management capabilities sufficient for the organization to organize, implement, and control the financial, marketing, benefit administration, and quality assurance activities related to the delivery of Part D services as required by 42 CFR §423.505(b)(25).

5.      PDP Sponsor agrees to provide applicable beneficiaries applicable discounts on applicable drugs in accordance with the requirements of 42 CFR Part 423 Subpart W.

 

	
C.

	
DISSEMINATION OF PLAN INFORMATION

1.  MA-PD Sponsor agrees to provide the information required in 42 CFR §423.48.

 

2.  MA-PD Sponsor acknowledges that CMS releases to the public summary reconciled Part D Payment data after the reconciliation of Part D Payments for the contract year as provided in 42 CFR §423.505(o).

 

3.  MA-PD Sponsor agrees to disclose information related to Part D benefits to beneficiaries in the manner and the form specified by CMS under 42 CFR §§423.128 and 423 Subpart V Marketing Requirements and in the Medicare Marketing Guidelines for Medicare Advantage-Prescription Drug Plans (MA-PDs) and Prescription Drug Plans (PDPs).

4.  MA-PD Sponsor certifies that all materials it submits to CMS under the File and Use Certification authority described in the Medicare Marketing Guidelines are accurate, truthful, not misleading, and consistent with CMS marketing guidelines.

 

	
D.

	
QUALITY ASSURANCE/UTILIZATION MANAGEMENT

 

1.  MA-PD Sponsor agrees to operate quality assurance, drug utilization management, and medication therapy management programs, and to support electronic prescribing in accordance with Subpart D of 42 CFR Part 423.

2.  MA-PD sponsor agrees to address complaints received by CMS against the Part D sponsor as required in 42 CFR §423.505(b)(22) by:

(a) Addressing and resolving complaints in the CMS complaint tracking system; and

(b) Displaying a link to the electronic complaint form on the Medicare.gov Internet Web site on the Part D plan's main Web page.

3.      PDP Sponsor agrees to maintain a Part D summary plan rating score of at least 3 stars as required by 42 CFR §423.505(b)(26).

	
E.

	
APPEALS AND GRIEVANCES

 

MA-PD Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part 423 governing coverage determinations, grievances and appeals, and formulary exceptions and the relevant provisions of Subpart U governing reopenings. MA-PD Sponsor acknowledges that these requirements are separate and distinct from the appeals and grievances requirements applicable to MA-PD Sponsor through the operation of its Part C or cost plan benefits.

 

	
F.

	
PAYMENT TO MA-PD SPONSOR

 

MA-PD Sponsor and CMS agree that payment paid for Part D services under the addendum will be governed by the rules in Subpart G of 42 CFR Part 423.

 

	
G.

	
BID SUBMISSION AND REVIEW

 

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If MA-PD Sponsor intends to participate in the Part D program for the next program year, MA-PD Sponsor agrees to submit the next year's Part D bid, including all required information on premiums, benefits, and cost-sharing, by the applicable due date, as provided in Subpart F of 42 CFR Part 423 so that CMS and MA-PD Sponsor may conduct negotiations regarding the terms and conditions of the proposed bid and benefit plan renewal. MA-PD Sponsor acknowledges that failure to submit a timely bid under this section may affect the sponsor's ability to offer a Part C plan, pursuant to the provisions of 42 CFR §422.4(c).

 

	
H.

	
COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

 

1.  MA-PD Sponsor agrees to comply with the coordination requirements with State Pharmacy Assistance Programs (SPAPs) and plans that provide other prescription drug coverage as described in Subpart J of 42 CFR Part 423.

 

2.  MA-PD Sponsor agrees to comply with Medicare Secondary Payer procedures as stated in 42 CFR §423.462.

 

	
I.

	
SERVICE AREA AND PHARMACY ACCESS

 

1.  MA-PD Sponsor agrees to provide Part D benefits in the service area for which it has been approved by CMS to offer Part C or cost plan benefits utilizing a pharmacy network and formulary approved by CMS that meet the requirements of 42 CFR §423.120.

 

2.  MA-PD Sponsor agrees to provide Part D benefits through out-of-network pharmacies according to 42 CFR §423.124.

 

3.  MA-PD Sponsor agrees to provide benefits by means of point-of-service systems to adjudicate prescription drug claims in a timely and efficient manner in compliance with CMS standards, except when necessary to provide access in underserved areas, I/T/U pharmacies (as defined in 42 CFR §423.100), and long-term care pharmacies (as defined in 42 CFR §423.100) according to 42 CFR §423.505(b)(17).

4.  MA-PD Sponsor agrees to contract with any pharmacy that meets MA-PD Sponsor's reasonable and relevant standard terms and conditions according to 42 CFR §423.505(b)(18).

 

5.  MA-PD Sponsor agrees to contract with any pharmacy that meets MA-PD Sponsor's reasonable and relevant standard terms and conditions. If MA-PD Sponsor has demonstrated that it historically fills 98% or more of its enrollees' prescriptions at pharmacies owned and operated by MA-PD Sponsor (or presents compelling circumstances that prevent the sponsor from meeting the 98% standard or demonstrates that its Part D plan design will enable the sponsor to meet the 98% standard during the contract year), this provision does not apply to MA-PD Sponsor's plan. 42 CFR§423.120(a)(7)(i)

6.  The provisions of 42 CFR §423.120(a) concerning the retail pharmacy access standard do not apply to MAPD Sponsor if the Sponsor has demonstrated to CMS that it historically fills more than 50% of its enrollees' prescriptions at pharmacies owned and operated by MA-PD Sponsor. MA-PD Sponsors excused from meeting the standard are required to demonstrate retail pharmacy access that meets the requirements of 42 CFR §422.112 for a Part C contractor and 42 CFR §417.416(e) for a cost plan contractor. 42 CFR§423.120(a)(7)(i)

 

	
J.

	
EFFECTIVE COMPLIANCE PROGRAM/PROGRAM INTEGRITY

 

MA-PD Sponsor agrees that it will develop and implement an effective compliance program that applies to its Part D-related operations, consistent with 42 CFR §423.504(b)(4)(vi).

 

	
K.

	
LOW-INCOME SUBSIDY

 

MA-PD Sponsor agrees that it will participate in the administration of subsidies for low-income subsidy eligible individuals according to Subpart P of 42 CFR Part 423.

 

	
L.

	
BENEFICIARY FINANCIAL PROTECTIONS

 

MA-PD Sponsor agrees to afford its enrollees protection from liability for payment of fees that are the obligation of MA-PD Sponsor in accordance with 42 CFR §423.505(g).

 

	
M.

	
RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES

 

 

	Page 4 of 9	 	 	 [_____]

 

  

  

  

1.  MA-PD Sponsor agrees that it maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of this addendum.

 

2.  MA-PD Sponsor shall ensure that any contracts or agreements with first tier, downstream, and related entities performing functions on MA-PD Sponsor's behalf related to the operation of the Part D benefit are in compliance with 42 CFR §423.505(i).

 

	
N.

	
CERTIFICATION OF DATA THAT DETERMINE PAYMENT

 

MA-PD Sponsor must provide certifications in accordance with 42 CFR §423.505(k).

 

	
O.

	
MA-PD SPONSOR REIMBURSEMENT TO PHARMACIES

 

1.  If MA-PD Sponsor uses a standard for reimbursement of pharmacies based on the cost of a drug, MA-PD Sponsor will update such standard not less frequently than once every 7 days, beginning with an initial update on January 1 of each year, to accurately reflect the market price of the drug.

 

2.  MA-PD Sponsor will issue, mail, or otherwise transmit payment with respect to all claims submitted by pharmacies (other than pharmacies that dispense drugs by mail order only, or are located in, or contract with, a long-term care facility) within 14 days of receipt of an electronically submitted claim or within 30 days of receipt of a claim submitted otherwise.

 

3.  MA-PD Sponsor must ensure that a pharmacy located in, or having a contract with, a long-term care facility will have not less than 30 days (but not more than 90 days) to submit claims to MA-PD Sponsor for reimbursement.

 

Article III

Record Retention and Reporting Requirements

 

	
A.

	
RECORD MAINTENANCE AND ACCESS

 

MA-PD Sponsor agrees to maintain records and provide access in accordance with 42 CFR §§ 423.505 (b)(10) and 423.505(i)(2).

 

	
B.

	
GENERAL REPORTING REQUIREMENTS

 

MA-PD Sponsor agrees to submit information to CMS according to 42 CFR §§423.505(f) and 423.514, and the "Final Medicare Part D Reporting Requirements," a document issued by CMS and subject to modification each program year.

 

	
C.

	
CMS LICENSE FOR USE OF PLAN FORMULARY

 

MA-PD Sponsor agrees to submit to CMS each plan's formulary information, including any changes to its formularies, and hereby grants to the Government, and any person or entity who might receive the formulary from the Government, a non-exclusive license to use all or any portion of the formulary for any purpose related to the administration of the Part D program, including without limitation publicly distributing, displaying, publishing or reconfiguration of the information in any medium, including www.medicare.gov, and by any electronic, print or other means of distribution.

 

Article IV

HIPAA Provisions

 

A.  MA-PD Sponsor agrees to comply with the confidentiality and enrollee record accuracy requirements specified in 42 CFR §423.136.

 

B.  MA-PD Sponsor agrees to enter into a business associate agreement with the entity with which CMS has contracted to track Medicare beneficiaries' true out-of-pocket costs.

 

	Page 5 of 9	 	 	 [_____]

 

  

  

  

 

Article V

Addendum Term and Renewal

 

	
A.

	
TERM OF ADDENDUM

 

This addendum is effective from the date of CMS' authorized representative's signature through December 31, 2013. This addendum shall be renewable for successive one-year periods thereafter according to 42 CFR §423.506.

 

	
B.  

	
QUALIFICATION TO RENEW ADDENDUM

 

 1.  In accordance with 42 CFR §423.507, MA-PD Sponsor will be determined qualified to renew this addendum annually only if—

 

(a) MA-PD Sponsor has not provided CMS with a notice of intention not to renew in accordance with Article VII of this addendum, and

 

(b)  CMS has not provided MA-PD Sponsor with a notice of intention not to renew.

 

2.  Although MA-PD Sponsor may be determined qualified to renew its addendum under this Article, if MA-PD Sponsor and CMS cannot reach agreement on the Part D bid under Subpart F of 42 CFR Part 423, no renewal takes place, and the failure to reach agreement is not subject to the appeals provisions in Subpart N of 42 CFR Parts 422 or 423. (Refer to Article X for consequences of non-renewal on the Part C contract and the ability to enter into a Part C contract.)

 

Article VI

Nonrenewal of Addendum

	
A.

	
NONRENEWAL BY MA-PD SPONSOR

 

1.  MA-PD Sponsor may non-renew this addendum in accordance with 42 CFR 423.507(a).

 

2.  If MA-PD Sponsor non-renews this addendum under this Article, CMS cannot enter into a Part D addendum with the organization or with an organization whose covered persons, as defined in 42 CFR §423.507(a)(4), also served as covered persons for the nonrenewing sponsor for 2 years unless there are special circumstances that warrant special consideration, as determined by CMS.

 

B.  NONRENEWAL BY CMS

 

CMS may non-renew this addendum under the rules of 42 CFR 423.507(b). (Refer to Article X for consequences of non-renewal on the Part C contract and the ability to enter into a Part C contract.)

 

Article VII

Modification or Termination of Addendum by Mutual Consent

 

This addendum may be modified or terminated at any time by written mutual consent in accordance with 42 CFR 423.508. (Refer to Article X for consequences of non-renewal on the Part C contract and the ability to enter into a Part C contract.)

 

Article VIII

Termination of Addendum by CMS

 

CMS may terminate this addendum in accordance with 42 CFR 423.509. (Refer to Article X for consequences of non-renewal on the Part C contract and the ability to enter into a Part C contract.)

 

Article IX

Termination of Addendum by MA-PD Sponsor

 

A.  MA-PD Sponsor may terminate this addendum only in accordance with 42 CFR 423.510.

 

	Page 6 of 9	 	 	 [_____]

  

  

  

 

B.  CMS will not enter into a Part D addendum with an MA-PD Sponsor that has terminated its addendum or with an organization whose covered persons, as defined in 42 CFR §423.508(f), also served as covered persons for the terminating sponsor within the preceding 2 years unless there are circumstances that warrant special consideration, as determined by CMS.

 

C.  If the addendum is terminated under section A of this Article, MA-PD Sponsor must ensure the timely transfer of any data or files. (Refer to Article X for consequences of non-renewal on the Part C contract and the ability to enter into a Part C contract.)

 

Article X

Relationship between Addendum and Part C Contract or 1876 Cost Contract

 

A.  MA-PD Sponsor acknowledges that, if it is a Medicare Part C contractor, the termination or nonrenewal of this addendum by either party may require CMS to terminate or non-renew the Sponsor's Part C contract in the event that such non-renewal or termination prevents MA-PD Sponsor from meeting the requirements of 42 CFR §422.4(c), in which case the Sponsor must provide the notices specified in this contract, as well as the notices specified under Subpart K of 42 CFR Part 422. MA-PD Sponsor also acknowledges that Article IX.B. of this addendum may prevent the sponsor from entering into a Part C contract for two years following an addendum termination or non-renewal where such non-renewal or termination prevents MA-PD Sponsor from meeting the requirements of 42 CFR §422.4(c).

 

B.  The termination of this addendum by either party shall not, by itself, relieve the parties from their obligations under the Part C or cost plan contracts to which this document is an addendum.

C.  In the event that MA-PD Sponsor's Part C or cost plan contract (as applicable) is terminated or nonrenewed by either party, the provisions of this addendum shall also terminate. In such an event, MA-PD Sponsor and CMS shall provide notice to enrollees and the public as described in this contract as well as 42 CFR Part 422, Subpart K or 42 CFR Part 417, Subpart K, as applicable.

 

Article XI

Intermediate Sanctions

 

Consistent with Subpart O of 42 CFR Part 423, MA-PD Sponsor shall be subject to sanctions and civil money penalties.

 

Article XII

Severability

 

Severability of the addendum shall be in accordance with 42 CFR §423.504(e).

 

Article XIII

Miscellaneous

 

A.  DEFINITIONS

Terms not otherwise defined in this addendum shall have the meaning given such terms at 42 CFR Part 423 or, as applicable, 42 CFR Part 422 or Part 417.

 

B.  ALTERATION TO ORIGINAL ADDENDUM TERMS

MA-PD Sponsor agrees that it has not altered in any way the terms of the MA-PD addendum presented for signature by CMS. MA-PD Sponsor agrees that any alterations to the original text MA-PD Sponsor may make to this addendum shall not be binding on the parties.

 

C.  ADDITIONAL CONTRACT TERMS

MA-PD Sponsor agrees to include in this addendum other terms and conditions in accordance with 42 CFR §423.505(j).

 

D.  CMS APPROVAL TO BEGIN MARKETING AND ENROLLMENT ACTIVITIES

 

	Page 7 of 9	 	 	 [_____]

  

  

  

 

MA-PD Sponsor agrees that it must complete CMS operational requirements related to its Part D benefit prior to receiving CMS approval to begin MA-PD plan marketing activities relating to its Part D benefit. Such activities include, but are not limited to, establishing and successfully testing connectivity with CMS systems to process enrollment applications (or contracting with an entity qualified to perform such functions on MA-PD Sponsor's behalf) and successfully demonstrating the capability to submit accurate and timely price comparison data. To establish and successfully test connectivity, MA-PD Sponsor must, 1) establish and test physical connectivity to the CMS data center, 2) acquire user identifications and passwords, 3) receive, store, and maintain data necessary to perform enrollments and send and receive transactions to and from CMS, and 4) check and receive transaction status information.

 

E.  Pursuant to §13112 of the American Recovery and Reinvestment Act of 2009 (ARRA), MA-PD Sponsor agrees that as it implements, acquires, or upgrades its health information technology systems, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under § 3004 of the Public Health Service Act, as amended by §13101 of the ARRA.

F.  MA-PD sponsor agrees to maintain a fiscally sound operation by at least maintaining a positive net worth (total assets exceed total liabilities) as required in 42 CFR §423.505(b)(23).

 

	Page 8 of 9	 	 	 [_____]

  

  

  

 

In witness whereof, the parties hereby execute this contract.

 

This document has been electronically signed by:

 

FOR THE MA ORGANIZATION

 

/s/ THOMAS TRAN

	  	  

 

Contracting Official Name

 

8/29/2012

	  	  

 

Date

 

                                                                              

	
 [                        ]

 

	  	
 [                      ]

	  
	
 

Organization

	  	
Address

	  

 

 

FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES

                                                                                                                                                 

 

	/s/ Cynthia Tudor   	 	 9/14/2012     	 
	 	 	 	 
	  

Cynthia Tudor, PhD

Director

Medicare Drug Benefit

and C&D Data Group,

Center for Medicare

	 	
 

Date

	 

 

 

	Page 9 of 9	 	 	 [_____]

 

  

  

  

DATA USE ATTESTATION

 

The sponsor shall restrict its use and disclosure of Medicare data obtained from CMS information systems (listed in Attachment A) to those purposes directly related to the administration of the Medicare managed care and/or outpatient prescription drug benefits for which it has contracted with the Centers for Medicare & Medicaid Services (CMS) to administer. The sponsor shall only maintain data obtained from CMS information systems that are needed to administer the Medicare managed care and/or outpatient prescription drug benefits that it has contracted with CMS to administer. The sponsor (or its subcontractors or other related entities) may not re-use or provide other entities access to the CMS information system, or data obtained from the system, to support any line of business other than the Medicare managed care and/or outpatient prescription drug benefit for which the sponsor contracted with CMS.

The sponsor further attests that it shall limit the use of information it obtains from its Medicare plan members to those purposes directly related to the administration of such plan. The sponsor acknowledges two exceptions to this limitation. First, the sponsor may provide its Medicare members information about non-health related services after obtaining consent from the members. Second, the sponsor may provide information about health-related services without obtaining prior member consent, as long as the sponsor affords the member an opportunity to elect not to receive such information.

CMS may terminate the sponsor's access to the CMS data systems immediately upon determining that the sponsor has used its access to a data system, data obtained from such systems, or data supplied by its Medicare members beyond the scope for which CMS has authorized under this agreement. A termination of this data use agreement may result in CMS terminating the sponsor's Medicare contract(s) on the basis that it is no longer qualified as a Medicare sponsor. This agreement shall remain in effect as long as the sponsor remains a Medicare managed care organization and/or outpatient prescription drug benefit sponsor. This agreement excludes any public use files or other publicly available reports or files that CMS makes available to the general public on our website.

 

	Page 1 of 3	 	 	 [_____]

  

  

  

 

Attachment A

 

The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency's information systems

 

Automated Plan Payment System (APPS)

Common Medicare Environment (CME)

Common Working File (CWF)

Coordination of Benefits Contractor (COBC)

Drug Data Processing System (DDPS)

Electronic Correspondence Referral System (ECRS)

Enrollment Database (EDB)

Financial Accounting and Control System (FACS)

Front End Risk Adjustment System (FERAS)

Health Plan Management System (HPMS), including Complaints Tracking and all other modules

HI Master Record (HIMR)

Individuals Authorized Access to CMS Computer Services (IACS)

Integrated User Interface (IUI)

Medicare Advantage Prescription Drug System (MARx)

Medicare Appeals System (MAS)

Medicare Beneficiary Database (MBD)

Payment Reconciliation System (PRS)

Premium Withholding System (PWS)

Prescription Drug Event Front End System (PDFS)

Retiree Drug System (RDS)

Risk Adjustments Processing Systems (RAPS)

 

	Page 2 of 3	 	 	 [_____]

  

  

  

 

This document has been electronically signed by:

 

 

/s/ THOMAS TRAN

	  	  

 

Contracting Official Name

 

8/29/2012

	  	  

 

Date

 

 

	
 [                      ]

 

	 	 	 

 

Organization

 

 

	
 [                      ]

 

	 	 	 

 

Address

 

 

	Page 3 of 3	 	 	 [_____]

  

  

  

 

SIGNATURE ATTESTATION

 

Contract ID: [_____]

Contract Name: [___________]

 

I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Health Plan Management System (HPMS) to sign the 2013 Medicare contracting documents. I also acknowledge that in accordance with the HPMS Rule of Behavior, sharing user IDs is strictly prohibited.

 

This document has been electronically signed by:

 

	  	  

 

/s/ THOMAS TRAN

	  	  

 

Contracting Official Name

 

8/29/2012

	  	  

 

Date

 

 

	
 [                      ]

 

	 	 	 

 

Organization

 

 

 

	
 [                      ]

 

	 	 	 

 

Address

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