Special Rules for Religious Fraternal Benefit (RFB) Societies

140 - Special Rules for Religious Fraternal Benefit (RFB) Societies (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) In order to participate as an MA organization, an RFB society may not impose any limitation on membership based on any factor related to health status and must offer in addition to the MA RFB plan, health coverage to individuals who are members of the church or convention or group of churches with which the society is affiliated, but who are not entitled to receive benefits from the Medicare program. Appendix A - Certification Of Monthly Enrollment and Payment Data Relating to CMS Payment to a Medicare Advantage Organization (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) Pursuant to the contract(s) between the Centers for Medicare & Medicaid Services (CMS) and (NAME OF MEDICARE ADVANTAGE ORGANIZATION), hereafter referred to as the “MA Organization,” governing the operation of the following Medicare Advantage plans (PLAN IDENTIFICATION NUMBERS ), the MA Organization hereby requests payment under the contract, and in doing so, makes the following certifications 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 and omissions to CMS about the accuracy of such information may result in Federal civil action and/or criminal prosecution. This certification 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 certification. 1. The MA Organization has reported to CMS for applications received in the month of (MONTH AND YEAR) all new enrollments, disenrollments, and changes in Plan Benefit Packages, as well as those beneficiaries who have met the qualifying institutional period with respect to the above-stated MA plans. Based on best knowledge, information, and belief, 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 _______________ (MONTH AND YEAR) for the above- stated MA plans and has submitted requests to the IntegriGuard, under separate cover, for retroactive adjustments to correct payment data when the MA Organization has more accurate information. This may include enrollment status, working aged status, institutional status, Medicaid status, and State and County Code related to specific beneficiary. 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 my best knowledge, information, and belief, to their accuracy, completeness, and truthfulness. _____________________________ NAME TITLE on behalf of _______________________________ (MA Organization)