Evaluation and Determination of Applications

20.2 - Evaluation and Determination of Applications (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) In order to obtain a determination on whether it meets the requirements to become an MA organization and will be qualified to provide a particular type of MA plan, an entity or an individual authorized to act for the entity must complete a certified application in the form and manner required by CMS, including the following: A. Documentation of appropriate State licensure or State certification that the entity is eligible, as a risk-bearing entity, to offer health insurance or health benefits coverage in the state or states in which it offers one or more plans, and is authorized by the State to accept prepaid capitation for providing, arranging, or paying for the comprehensive health care services to be offered under the MA contract; or documentation of a Federal waiver; or B. For regional plan, documentation of application for State licensure in any State in the region that the organization is not already licensed. C. The authorized individual must describe thoroughly how the entity and MA plan meet, or will meet the requirements for meeting its obligations under 42 CFR Part 422. NOTE: An applicant submitting material that he or she believes is protected from disclosure under 5 U.S.C. 552, the Freedom of Information Act (FOIA), or because of exceptions provided in 45 CFR Part 5 (the Department of Health and Human Service's regulations providing exceptions to disclosure), should label the material "privileged" and include an explanation of the applicability of an exception described in 45 CFR Part 5. The foregoing is not a pledge of confidentiality, and the applicant’s labeling of material as confidential or privileged does not exempt such material from undergoing FOIA review by CMS. Other requirements concerning the evaluation of applications include the following: A. CMS is responsible for determining whether an entity qualifies as an MA organization and whether proposed MA plan(s) meet(s) the requirements for obtaining a contract under 42 CFR Part 422. B. A CMS determination that an entity is qualified to act as an MA organization is distinct from the bid negotiation that occurs under 42 CFR Part 422 Subpart F and such negotiation is not subject to the appeals provisions included in Subpart N of that part. C. An application that has been denied by CMS may not be resubmitted for 4 months after the date of the notice from CMS denying the application. CMS evaluates an application for an MA contract on the basis of information contained in the application itself and any additional information that CMS obtains through on-site visits, public hearings, and any other appropriate procedures. If the application is incomplete, CMS will make all efforts to notify the entity and allows 2 days from the date of the notice for the entity to furnish the missing information. Please note, however, that such notification is not required of CMS and, if the entity does not respond within the 2 days, the entity risks receiving an intent to deny notice as described below. After evaluating all relevant information, CMS determines whether the entity's application meets the requirements in section of 42 CFR §422.501. CMS notifies each entity that applies for an MA contract of its determination and the basis for the determination. The determination may be approval, intent to deny or denial. If CMS approves the application, it gives written notice to the MA organization, indicating that it meets the requirements for an MA contract. If CMS finds that the entity does not appear to meet the requirements to be an MA contracting organization, and/or has not provided enough information to enable CMS to evaluate the application, CMS gives the entity notice of intent to deny qualification and a summary of the basis for this preliminary finding. Within 10 days from the date of the notice, the entity may respond in writing to the issues or other matters that were the basis for CMS' preliminary finding and may revise its application to remedy any defects CMS identified. If CMS denies the application, it gives written notice to the entity indicating: a. That the entity is not qualified to contract as an MA organization under Part C of Title XVIII of the Act; b. The reasons why the entity does not meet the contract requirements; and c. The entity's right to request reconsideration in accordance with the procedures specified in Subpart N of the MA regulations at 42 CFR Part 422. CMS oversees an entity's continued compliance with the requirements for an MA organization. If an entity no longer meets those requirements CMS terminates the contract in accordance with procedures described in Subpart K at 42 CFR Part 422. NOTE: If an entity has failed to comply with the terms of a previous year’s contract with CMS under Title XVIII of the Social Security Act as an HMO, competitive medical plan, health care prepayment plan, or MA organization, or if an entity has failed to complete a corrective action plan during the term of its contract, CMS may deny a future application based on the entity’s failure to comply with that prior contract with CMS, even if the entity meets all of the current requirements.