SNF Training, SNP Model of Care Training, and Medicare Marketing Guidelines
In accordance with Centers for Medicare and Medicaid Services (CMS) regulations, Medicare Advantage organizations (MAOs) are required to establish, implement and ensure that all first-tier, downstream and related entities (FDRs) have taken and reviewed the following trainings and educational materials:
SNF Training – Jimmo v. Sebelius Settlement
CMS recently issued a requirement related to the settlement of the 2013 Jimmo v. Sebelius class action lawsuit. The settlement addresses the delivery of skilled nursing services to Medicare beneficiaries and applies to nursing facilities, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).
All Medicare providers are required to review this training in order to ensure that services are provided and coverage determinations are adjudicated accurately and appropriately in accordance with existing Medicare policy.
Model of Care Initial and Annual Training
The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations (MAOs) to provide initial and annual Model of Care training for Special Needs Plans (SNP) and those participating in Medicare Medicaid Plans (MMP or Cal MediConnect). In accordance with the regulations, Health Net has developed the SNP/MMP Model of Care training. This requirement is applicable to SNP/MMP providers only.
CMS requires that SNP/MMP providers and appropriate staff (those involved in the provision of SNP/MMP services) complete the Model of Care training each year by December 31. The training can be provided in a variety of modalities, such as printed, face-to-face, or online Web-based formats. SNP/MMP providers do not have to submit confirmation of training upon completion; however, providers are subject to audit by CMS and Health Net to demonstrate that the training was provided to appropriate staff. Therefore, providers must maintain training records, which may consist of a mailing list, fax list, sign-in sheet, or other formats. You can use the Model of Care training that Health Net has provided here to fulfill this requirement. Remember to provide Model of Care training to new hires in addition to annually for existing staff.
Medicare Marketing Guidelines
The Centers for Medicare and Medicaid Services (CMS) Medicare Managed Care Manual provides specific guidance regarding marketing communications to Medicare-eligible members by health plans and their participating providers. Health Net participating providers are required to comply with applicable Medicare laws and regulations, and Health Net policies and procedures when creating or distributing marketing materials.
The Health Net policies and procedures for submitting marketing materials is available on Health Net's provider website in the Health Net Provider Library under Operations Manuals > Compliance and Regulations > CMS Provider Marketing Guidelines. For additional questions regarding Medicare marketing materials submission, or to submit Medicare marketing materials for approval, contact the Health Net Medicare Marketing Department by email.
For updated and additional information regarding CMS Medicare marketing guidelines, refer to the CMS website at:
Issue Identification, Tracking, Escalation, and Resolution Training
The Centers for Medicare and Medicaid Services (CMS) requires that Health Net operate in compliance with CMS regulations and report any issues that may be out of compliance. Therefore, Health Net requires that all Medicare Advantage (MA) first-tier, downstream and related entities (FDRs) report any issues that may be considered out of compliance to their Health Net business contact immediately upon learning of the incident. In addition, FDRs may report potential issues that may be considered out of compliance to Health Net as follows:
- Health Net Medicare Compliance Officer
21650 Oxnard Street, Mail Stop: CA-102-24-23
Woodland Hills, CA 91367
- You can also report via:
- Fraud, Waste & Abuse Helpline: 1-866-685-8664
- Ethics & Compliance Helpline: 1-800-345-1642
All Health Net first-tier providers (those who hold a direct contract with Health Net) and downstream providers (entities with which a first-tier entity contracts to provide services to MA members) and first-tier and downstream employees must complete this training. First-tier entities are responsible for their downstream entities' completion of the training. Training must be completed annually by December 31 and must also be a part of orientation for new employees. This is subject to audit upon request from Health Net. This process is not related to and is separate from any provider appeals and grievance processes.
- Select Issue Identification, Tracking, Escalation, and Resolution Training (PDF) to begin the training
First-tier entities may download and distribute this training to their downstream providers.
Once a first-tier entity has completed the training, no further action is required. There are no acknowledgment or attestation forms to be returned to Health Net. First-tier entities must have documentation that the training was distributed to all of its employees and downstream entities and employees, as applicable, readily available for audit upon request from Health Net in the form of a mailing list, fax list or other equivalent format. Downstream entities do not need to submit acknowledgment or attestation forms to first-tier providers. Policies and procedures should also reflect inclusion of the training in new employee orientation processes.
Code of Business Conduct & Ethics
The Code of Business Conduct and Ethics is the cornerstone of Health Net's enterprise-wide compliance and ethics program and includes values and principles regarding acceptable business conduct. Honesty, integrity, transparency, and accountability are key concepts that Health Net embraces.
It is important that providers and first-tier, downstream and related entities (FDRs) read the Code of Business Conduct and Ethics in its entirety.
Health Net expects all Health Net providers and FDRs to read and understand Health Net standards of conduct and report any suspected violations of those standards. Health Net Providers and FDRs must ensure distribution of the standards of conduct to their employees and downstream entities within 90 days of hire, when updated, and annually thereafter.
Updates to Covered Benefits
Occasionally, the Centers for Medicare and Medicaid Services (CMS) will make mid-year changes to Original Medicare. These are known as National Coverage Determinations (NCDs).
Newly Required Preventive Services
The following preventive services are covered without cost-share, retroactive to October 14, 2011, according to the CMS' National Coverage Determination (NCD):
- Screening and behavioral counseling interventions in primary care to reduce alcohol misuse
- Screening for depression in adults in a primary care setting
The following preventive services are covered without cost-share, retroactive to November 8, 2011, according to the CMS' NCD:
- Screening for sexually transmitted infections (STIs)
- High-intensity behavioral counseling to prevent STIs
The following preventive services are covered without cost-share, retroactive to November 29, 2011, according to the CMS' NCD:
- Screening for obesity and counseling for eligible beneficiaries by primary care providers
If you have questions regarding this information, refer to CMS' Web sites at CMS Coverage Email Updates and News and Announcements and select the applicable CMS press release. For all other questions, contact the applicable Health Net Provider Services Center.
Medicare Advantage Precluded Provider Listing Monitoring
Precluded Provider Listing Monitoring
On November 2, 2018, and December 14, 2018, the Centers for Medicare & Medicaid Services (CMS) sent notifications to Health Net for time frames and requirements about the CMS precluded provider listing.
This list is comprised of providers who have engaged in behavior that CMS determines is detrimental or who are under an active reenrollment bar that CMS determines is detrimental to the best interests of the Medicare program.
Effective January 1, 2019, CMS requires that Health Net and its delegated entities follow these time frames:
- Health Net posts the list of precluded providers on the HealthNet.com provider portal for delegated participating physician groups (PPGs) and delegated hospitals to access on a monthly basis after CMS updates it.
- The data file includes eligible employer identification numbers (EINs), also referred to as the tax identification number, and National Provider Identifiers (NPIs) or only NPI for those providers on the precluded list. Because EINs are protected health information (PHI), Health Net has truncated them to include only the last four digits, which is sufficient to determine a match.
- Monthly Precluded Data File (XLSX)
- Health Net and their delegated entities notify impacted providers no later than 30 days from the CMS posting of the precluded provider list with a list of those Medicare Advantage (MA) members who are losing access to the impacted provider (this does not apply to non-choice providers, such as emergency room (ER) physicians or pathologists).
- Health Net and their delegated entities notify members as soon as possible and no later than 30 days from the CMS posting of the list. Delegated entities are responsible to notify members when they pay claims from impacted providers.
- Advance notice to members at least 60 days before claims are denied for services furnished by the provider on the list and for members to find another provider. Also applies to members who had services through/with or prescriptions written by the impacted provider in the previous 12 months.
- Health Net does not deny payments/reject claims or member reimbursements earlier than 90 days after the publication of the precluded provider listing.
- Health Net removes impacted providers from Health Net's network at the end of the 90-day time frame, including individual providers and entities.
90-Day Notification Time Frame Example
This is an example of the notification time frame for the initial precluded provider listing:
- The initial precluded provider listing* is posted January 1, 2019.
- Health Net sends notification to the impacted members by January 31, 2019.
- On April 1, 2019, Health Net begins denying payment/rejecting claims based on January 1, 2019, initial precluded provider list, with dates of service (DOS) April 1, 2019, and after.
*Follow this same process for monthly updates to the precluded provider listing as for the initial list.
Medicare Advantage Provider Exclusions Monitoring
The Centers for Medicare and Medicaid Services (CMS) require contractors and their First Tier Downstream and Related entities (FDRs) to monitor federal exclusions lists. The parties/entities on these lists are excluded from various activities, including rendering services to Medicare enrollees (unless in the case of an emergency, 42 CFR § 1001.1901) and from being employed or contracted to render services to Medicare enrollees. Health Net requires that its participating physician groups (PPGs), hospitals, ancillary providers, and physicians continuously monitor federal exclusion lists. The information below provides the names of each federal exclusion list, governing regulations and CMS guidance, including links to publicly available exclusion lists.
Health Net and FDR Hiring And Contracting Responsibilities
Health Net and their First Tier Downstream and Related entities (FDRs) are required to monitor federal exclusion lists to ensure that Health Net and their First Tier Downstream and Related entities (FDRs) are not hiring, contracting or paying excluded parties or entities for services rendered to enrollees in Health Net's MA and MA-PD plans. MAOs and their FDRs must check the List of Excluded Individuals and Entities (LEIE) and Exclusions Extract Data Package (EEDP) federal exclusion lists prior to hiring or contracting with any new employee, temporary employee, volunteer, consultant, governing body member, or FDR for Part C- and Part D related activities. MAOs and their FDRs must continuously monitor these lists at least monthly to ensure parties or entities that were previously screened have not become excluded later.
List of Excluded Individuals and Entities (LEIE)
The Office of the Inspector General -- Health and Human Services, (OIG-HHS) imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act.
- A list of all exclusions and their statutory authority are available on the Exclusion Authority website.
- The current LEIE is available on the OIG-HHS website.
- Frequently asked questions (FAQs) and additional information on the LEIE.
Exclusions Extract Data Package (EEDP)
The General Services Administration (GSA's) EEDP is a government-wide compilation of various federal agency exclusions, and replaces the Excluded Parties List System (EPLS). Exclusions contained in the EEDP are governed by each agency's regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion databases. All parties or entities listed on the EEDP are subject to exclusion from Medicare participation. The current EEDP is available on the SAM website.
Health Net and FDR Payment Responsibilities
Health Net and their First Tier Downstream and Related entities (FDRs): PPGs, hospitals, and ancillary providers cannot pay participating and non-participating parties or entities included on these lists for any services using federal funds, except as documented in the CMS Internet Only Manual, publication 100-16, Chapter 6 -- Relationships with Providers, which states, "The OIG has a limited exception that permits payment for emergency services provided by excluded providers under certain circumstances. See 42 CFR § 1001.1901." FDRs contracting with Health Net and their First Tier Downstream and Related entities (FDRs) must have a documented process in place to ensure compliance with these guidelines, and notify enrollees who obtain services from excluded parties and make claims payments as allowed under these exceptions. This documentation is subject to audit upon request from Health Net or CMS.
Governing Regulation and CMS Guidance
The names of parties that have been excluded from Medicare participation are published in the Office of the Inspector General U.S. Department of Health and Human Services (OIGHHS) List of Excluded Individuals and Entities (LEIE), and on the General Services Administration's (GSA) Exclusions Extract Data Package (EEDP) (or Excluded Parties List System (EPLS), which was replaced by the EEDP), as referenced through the System for Award Management (SAM) website at www.sam.gov. Medicare Advantage organizations (MAOs) and their FDRs must abide by the regulations documented in the Social Security Act 1862(e)(1)(B), 42 CFR §422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6), and 1001.1901. These federal exclusion requirements are further interpreted and communicated as guidance by CMS in Medicare Manual, Volume 100-16, Chapters 9 and 21 §50.6.8. Additional regulations that require sponsors to include CMS requirements in their contracts, as well as monitor their FDRs, are available in 42 CFR §422.504(i)(4)(B)(v) and 423.505(i)(3)(v).