PART C -MEDICARE ADVANTAGE and 1876 COST PLAN …

1 2023 Part C Application Page 1 of 120 PART C - medicare ADVANTAGE and 1876 COST PLAN EXPANSION APPLICATION For all new applicants and existing medicare ADVANTAGE organizations seeking to expand a service are a: Coordinate d Care Plans, Private Fee-for-Se rvice Plans, medicare Savings Account plans, and Employer Group Waiver Plans For all existing medicare Cost Plan contractors seeking to expand the contract service area DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for medicare & Medicaid Services (CMS) Center for medicare (CM) medicare Drug and Health Plan Contract Administration Group (MCAG) In accordance with 42 CFR (c) and Chapter 4 section of the MMCM, in order to offer a medicare ADVANTAGE Coordinate d Care Plan (CCPs)

2 In an are a, a medicare ADVANTAGE organization must offer qualified Part D coverage meeting 42 CFR in that plan or in another medicare ADVANTAGE plan in the same area. Therefore, CCP applicants may need to submit a separate Part D application (in conne ction with this Part C Application) to offer Part D pre scription drug be ne fits as a condition for approval of this application. DISCLAIMER: CMS will only accept applications appropriately submitted through the Health Plan Management System. CMS does not accept paper applications. PUBLIC REPORTING BURDEN: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

3 The valid OMB control number for this information collection is 0938-0935 (Expires: December 2022). The time required to complete this information collection is estimated to average 33 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have any comments, concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Expiration: December 2022 GENERAL INFORMATION .. 4 Overview .. 4 Types of MA Products .. 4 2023 Part C Application Page 2 of 120 Important References.

4 5 Technical Support .. 5 The Health Plan Management System (HPMS) .. 5 Submitting Notice of Intent to Apply (NOIA) .. 6 Additional Information .. 7 Due Dates for Applications medicare ADVANTAGE and medicare Cost Plans .. 9 Request to Modify a Pending Application .. 9 Application Determination and Appeal Rights .. 10 INSTRUCTIONS .. 10 Overview .. 10 Applicants Seeking to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) .. 11 Applicants Seeking to Offer Employer/Union Direct Contract MAO .. 11 Applicants Seeking to Offer Special Needs Plans (SNPs) .. 12 Applicants Seeking to Offer New MA D-SNP Look-Alike Plans .. 12 Applicants Seeking to Expand medicare Cost Plans.

5 15 Applicants Seeking to Serve Partial Counties .. 13 Types of Applications .. 13 Chart of Required Attestations by Type of Applicant .. 14 Document (Upload) Submission Instructions .. 16 MA Part D (MA-PD) Prescription Drug Benefit Instructions .. 16 ATTESTATIONS .. 17 Management, Experience, and History .. 20 Administrative Management .. 19 State Licensure .. 19 Program Integrity .. 22 Fiscal Soundness .. 22 Service Area .. 23 CMS Provider Participation Contracts & Agreements .. 25 Contracts for Administrative & Management Services .. 26 Quality Improvement Program .. 27 Marketing .. 28 Eligibility, Enrollment, and Disenrollment .. 28 Working Aged Membership.

6 29 Claims .. 30 Communications between MAO and CMS .. 30 Grievances .. 31 Organization Determination and Appeals .. 32 Health Insurance Portability and Accountability Act of 1996 (HIPAA) and CMS issued guidance on 07/23/2007 and 8/28/2007; 2008 Ca ll Letter .. 35 Continuation Area .. 36 Part C Application Certification .. 37 Access to Services (PFFS) .. 37 Claims Processing (PFFS and MSA) .. 41 Payment Provisions (PFFS and MSA) .. 42 General Administration/Management (MSA) .. 44 2023 Part C Application Page 3 of 120 Past Performance .. 45 Document Upload Templates .. 46 History/Structure/Organizational Charts .. 46 Minimum Enrollment Waiver Request Upload Document.

7 47 Two Year Prohibition Waiver Request Upload Document .. 48 CMS State Certification Form .. 49 Part C Application Certification Form .. 55 RPPO State Licensure Table .. 56 RPPO State Licensure Attestation .. 57 Partial County Justification .. 58 APPENDIX I: Solicitations for Special Needs Plan (SNP) Application .. 60 Overview .. 60 SNP Application Types .. 61 Renewal SNPs that are Not Expanding their Service Area .. 61 D-SNP State Medicaid Agency(ies) Contract(s): Attestation and Uploads .. 63 I-SNP: Attestations and Uploads .. 65 MOC: Attestation and Uploads .. 66 Health Risk Assessment: Attestations .. 67 SNP Quality Improvement Program: Attestations .. 69 Past Performance Attestation.

8 71 D-SNP State Medicaid Agency Contract Matrix .. 72 Special Needs Plan (SNP) Contract Review Matrix .. 76 I-SNP Upload Documents .. 79 MOC Matrix Upload Document for Initial Application and Renewal .. 83 APPENDIX II: Employer/Union-Only Group Waiver Plans (EGWPs) MAO 800 Series .. 92 Background .. 92 Instructions .. 92 Request for Additional Waivers/Modification of Requirements (Optional) .. 93 Attestations .. 93 APPENDIX III: Employer/Union Direct Contract for MA .. 99 Background .. 99 Instructions .. 99 Request for Additional Waivers/Modification of Requirements (Optional) .. 100 Attestations .. 101 Part C Financial Solvency & Capital Adequacy Documentation For Direct Contract MAO applicants.

9 105 2023 Part C Application Page 4 of 120 GENERAL INFORMATION Overview The medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) significantly revised the medicare + Choice managed care program, now called the medicare ADVANTAGE (MA) program, and added outpatient prescription drugs to medicare , offered by either stand-alone prescription drug plan sponsors or medicare ADVANTAGE Organizations (MAOs). The MMA changes make managed care more accessible, efficient, and attractive to beneficiaries seeking options to meet their needs. Pursuant to 42 CFR , the MA program offers several kinds of plans and health care choices, including a coordinated care plans, medicare Savings Account (MSA) plans, or Private Fee-for-Service (PFFS) plans.

10 People with medicare not only have more quality health care choices than in the past but also have more information about those choices. The Centers for medicare & Medicaid Services (CMS) welcomes organizations that can add value to these programs, make them more accessible to medicare beneficiaries, and meet all the contracting requirements. Types of MA Products The MA program is comprised of a variety of product types, including: Coordinated Care Plans (CCPs) Health Maintenance Organizations (HMOs) with or without a Point of Service (POS) benefit Local Preferred Provider Organizations (LPPOs) Regional Preferred Provider Organizations (RPPOs) Special Needs Plans (SNPs) Private Fee-for-Service (PFFS) plans Medical Savings Account (MSA) plans Employer Group Waiver plans (EGWPs) Qualifying organizations may contract with CMS to offer any of these types of products.