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Medicare FWA, General Compliance and 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:


Medicare FWA Training, General Compliance Training and Annual Attestation

Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs) to ensure their first-tier, downstream and related entities (FDRs), including FDR employees who are in critical roles related to any delegated functions, receive general compliance training as well as fraud, waste and abuse (FWA) training, and that a monitoring process is in place to ensure the training is completed by December 31 of each year. FDRs are prohibited from developing, implementing or completing supplemental trainings to fulfil this requirement. FDRs must access the CMS standardized course modules available at the CMS Medicare Learning Network website at:

For Cal MediConnect Plan (Medicare–Medi-Cal Plan) participating providers, these requirements are Medicare-specific, and not applicable to Medi-Cal.


FWA and General Compliance Training Requirements

Health Net participating physician groups (PPGs), independent practice associations (IPAs) and medical groups delegated to perform administrative functions, such as claims processing, credentialing or utilization management, on Health Net's behalf, are required to ensure that their employees who are in critical roles related to these delegated functions complete the CMS-developed FWA and general compliance training. The training must occur within 90 days of initial hiring and annually thereafter. The annual training can be completed any time between January 1 and December 31. In accordance with CMS guidance, examples of the critical roles within a PPG, IPA and medical group that should clearly be required to fulfill these training requirements include the following positions or roles:

  • Senior administrators or managers directly responsible for the PPG's, IPA's or medical group's contract with Health Net, such as senior vice president, departmental managers or chief medical officer;
  • Individuals directly involved with establishing and administering any administrative function, such as claims processing, credentialing or utilization management, and/or medical benefits coverage policies and procedures, on Health Net's behalf;
  • Individuals involved with decision-making authority on behalf of Health Net, such as clinical decisions, coverage determinations, credentialing, or processing of medical claims;
  • Reviewers of beneficiary claims and services submitted for payment; or
  • Individuals with job functions that place the PPG, IPA and medical group in a position to commit significant noncompliance with CMS program requirements or health care FWA.

Delegated PPGs, IPAs, and medical groups that can provide evidence that they are deemed to have met the FWA training and education requirements due to their enrollment in Medicare Parts A or B, or have accreditation as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DME-POS), only need their employees to complete the CMS-developed general compliance training.

There are two options from which delegated PPGs, IPAs and medical groups can choose to fulfill these training requirements:

  • Direct employees to complete the FWA and/or general compliance training modules through the CMS Medicare Learning Network website. Once an individual completes the training, the system generates a certificate of completion that the PPG, IPA or medical group, collects and tracks on an annual basis as indicated below under Training Attestation Record Maintenance Requirements.
  • The PPG, IPA or medical group can download and incorporate the content of the CMS standardized training modules from the CMS Medicare Learning Network website into their organization's existing compliance training materials and systems. According to CMS, the training content cannot be modified; however, CMS allows modifications to the appearance of the content, such as font, color, background, and format, and allows organizations to augment the CMS training content by adding topics specific to their organization or the employee's job function.

The CMS Medicare Parts C and D General Compliance Training (January 2017) and the Combating Medicare Parts C and D Fraud, Waste, and Abuse Training (January 2017) are accessible through the CMS Medicare Learning Network website at:

Providers must create an account to access the training. To create an account, select the Create Account link. Once logged in, use the search engine to search for each training module. A certificate of completion is generated upon passing a short test with a score of 70 percent or higher at the end of each training module. CMS may update the training modules, so providers must ensure their employees take the most recent course provided by CMS.

Training Attestation Record Maintenance Requirements

By March 31 of each year, delegated PPGs, IPAs and medical groups are required to attest that all identified staff completed the FWA and general compliance training in the prior year. A parent PPG, IPA or medical group may submit one attestation on behalf of itself and its satellites by listing each satellite including the National Provider Identifier (NPI) or tax identification number (TIN) on the attestation. The attestation form may be sent to Health Net’s Provider Services Operations Department via:

There is an option on the attestation to indicate whether a PPG meets the deeming requirement for FWA and which option was selected for how their employees accessed the CMS modules. Providers may access the attestation form and requirements in the Health Net Provider Library under Operations Manuals > Provider Oversight > Fraud, Waste and Abuse and General Compliance Training > Training and Attestation Requirements.

Delegated PPGs, IPAs and medical groups are accountable for maintaining FWA and general compliance training records for a period of 10 years. The type of training records may include certificates of completion, training logs, system generated reports, or spreadsheets. At a minimum, employee names, dates of employment, dates of training completion, and passing scores (if captured) must be included to clearly document training completion. Health Net routinely monitors for compliance with these requirements, and this information is subject to audit upon request from Health Net or CMS.


CMS FWA and General Compliance Requirements

The FWA and general compliance training requirements are based on the following CMS regulations and requirements:

  • Title 42 Code of Federal Regulations (CFR) 422.503(b)(4)(vi)(C)(1)-(3), 423.504(b)(4)(vi)(C)(1)-(4)
  • CMS Medicare Managed Care Manual, Chapter 21 – Compliance Program Guidelines, and Prescription Drug Benefit Manual Chapter 9 – Compliance Program Guidelines, Section 40: Sponsor Accountability for and Oversight of FDRs and Section 50.3: Element III: Effective Training and Education
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.

Special Needs Plans Model of Care Initial & Annual Training

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations (MAOs) to provide annual Special Needs Plans (SNP) Model of Care Annual training for all SNP participating providers (§422.102(f)(2)(ii)). In accordance with the regulations, Health Net has developed the SNP Model of Care Annual training. This requirement is applicable to SNP providers only.

CMS requires that SNP providers and appropriate staff (those involved in any aspect of the provision of SNP services) complete the SNP model of care annual training each year by December 31. The training can be provided in any of a variety of modalities, such as printed, face-to-face, Web-based, or audio and visual formats. SNP 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. If you choose to use the model of care annual training that Health Net created, select SNP Model of Care Annual Training (pdf) to open the file and begin the training.

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 at:

For updated and additional information regarding CMS Medicare marketing guidelines, refer to the CMS website at:

Issue Identification, Tracking, Escalation, and Resolution Training

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
    Donovan Ayers
    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.

First-tier entities may download and distribute this training to their downstream providers.


Documentation Retention

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.

Centene Corporation Business Ethics and Conduct Policy

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

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

Additional Information

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 Provider Exclusions Monitoring

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 publically available exclusion lists.

HEALTH NET AND FDR HIRING AND CONTRACING 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.

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 at: www.sam.gov, with additional information located under Help > User Guides > Quick User Guides > Helpful Hints for Public Users.

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 ww.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).

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Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


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Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
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