MA Oversight and Beneficiary Protection Guidance

110.3 - MA Oversight and Beneficiary Protection Guidance (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) MA organizations, provider groups, individual providers and CMS have a common interest in preventing delegated provider group financial difficulties that may negatively impact the well being of Medicare beneficiaries. Similarly, these parties share an interest in mitigating the impact that provider group failures might have upon Medicare beneficiaries enrolled in an MA product. The following is a list of MA regulations that are relevant to MA organizations that have relationships with delegated entities. These requirements hold MA organizations responsible for providing care to Medicare beneficiaries, and for protecting Medicare beneficiaries in instances where delegated entities experience operational difficulties that may result in failure of the delegated entity to perform delegated functions. • 422.100(a) - an MA organization offering an MA plan must provide enrollees in that plan with coverage of the (plan benefit package) by furnishing the services directly or through arrangements, or by paying for the benefits; • 422.112(b) - The MA organization must ensure continuity of care and integration of services; • 422.504(g)(1) - 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; • 422.504(i)(1) - Notwithstanding any relationship(s) that the MA organization may have with related entities, contractors, or subcontractors, the MA organization maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with CMS; • 422.502(i)(4)(i)-(v) - If any of the MA organization's activities or responsibilities under its contract with CMS are delegated to other parties, written arrangements must specify that the performance of the parties is monitored by the MA organization on an ongoing basis, and either provide for revocation of the delegated activities or specify other remedies where CMS or the MA organization determines such parties have not performed satisfactorily. The policies and procedures described in §110.4 are recommended but not required for MA Organizations to ensure the operational integrity of delegated entities, and to protect beneficiaries in the event of a delegated provider group(s) insolvency and/or termination. This additional guidance may prove helpful to MA organizations in their attempt to meet the aforementioned MA regulatory requirements.