{"text_format":"2","workbook":"xls","n_sheets":1,"sheets":["CY 2012 Applications 8-9-10"],"not_rendered":{"charts":0,"images":0,"macros":0,"external_links":1,"defined_names":2,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"run_cost":"one","rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"CY 2012 Applications 8-9-10","index":0,"n_rows":33,"n_cols":5,"rows_kept":33,"cut":false,"hidden":false,"merged":[[1,0,1,4],[7,0,7,4],[23,0,23,4]],"flags":["formulas_cached_only"]}
["Document (MA, PDP or MA-PD Application, Facility Table, etc.","Section # (if applicable)","Page #","Description of Issue/Concern","Suggested Revision or \nRecommended Comment"]
["Part C, MA Application"]
["Part C, MA",2.1,"15","Instructions - clarifies what it means to respond \"Yes\" to an attestation.  \"By responding \"Yes,\" the Applicant is committing that its organization complies with the relevant requirements as of the date the application is submitted to CMS.\" The 2011 application indicated that \"Yes\" meant that the plan will be compliant as of the date of the contract, unless an earlier date is stated. ","We do not think responding Yes should always mean that the applicant is currently compliant with the attestation.  For example, an applicant could be new to Medicare and would be unable to say that it currently complies with an operational requirement that it does not yet perform.  Additionally, if a rule did not go into effect until the next calendar year, plans could not attest on the application they are currently compliant.  Finally, an applicant might have a contract for a particular service that does not go into effect until the beginning of the plan year for which the application is filed.  The plan should not have to attest that it has the contract in place at the time of the application when it is not necessary until the beginning of the plan year."]
["Part C, MA",3.9,"31","CMS Provider Participation Contracts & Agreements. Attestation #4: \"Applicant agrees to have all provider contracts and/or agreements available upon request and onsite.\" This attestation is unchanged from last year, but an applicant may utilize off-site storage vendors for some contracts while storing others electronically or onsite.  For the purposes of sampling for an application or at other times, plans could agree to have contracts available onsite upon request. ","We recommend that the wording of the attestation be clarified.  We believe that CMS is requesting that plans have the provider contracts onsite for review, but is not requiring that plans have the contracts on-site at all times.  A plan may have many of it's contracts off-site, but can certainly access them and bring them on-site if needed.  In order to clarify what CMS is requiring, we would make the following suggested wording change: \"Applicant agrees to have all provider contracts and/or agreements available onsite upon request.\""]
["Part C, MA",3.1,"32","Contracts for Administrative & Management Services. All the attestations that had \"will have\" have been revised to \"has.\"  \"Example: Applicant has an administrative/management contract/agreement with a delegated entity to perform…\"  This supports the change made in the instructions which explains that a \"yes\" indicated that the plan can comply as of the date of the application.","As indicated in the previous comment, the revisions would require that plans have contracts in place at the time the application is submitted.  However, a plan may reasonably have a contract that does not become effective until the beginning of the plan year.  We recommend CMS revise the attestations to reflect the previous wording, that plans \"will have\" contracts/agreements in place."]
["Part C, MA",3.15,"44","Attestation #1 reads: “Applicant will date and time stamp all claims as they are received, whether in paper form or via electronic submission, in a manner that is acceptable to CMS.\" We suggest the removal of the words \"and time\" to allow plans that utilize claims systems that date stamp, but do not currently also time stamp to answer Yes.","We recommend that attestation #1 be revised to read as follows: \n\"Applicant will date stamp all claims as they are received, whether in paper form or via electronic submission, in a manner that is acceptable to CMS.\" "]
["Part C, MA",3.15,"44","Attestation #2 reads: “Applicant will ensure that all claims are processed in chronological order, by date of receipt.”  Plans may generally process claims in the order in which they are received. However, in order to process claims in a more efficient manner, plans may not always process claims strictly in chronological order.  For example, while a large volume of claims will auto-adjudicate a smaller number of claims may require manual intervention to process. Claims are not cleared in the same order they are received because some require more work than others.  Also, auto-adjudicated claims are processed before claims requiring manual work even if the manual claims are received earlier. ","We recommend that attestation #2 be revised to read as follows: \n\"Applicant will ensure that all claims are processed promptly and in accordance with CMS regulations and guidelines.”  We think that this change in the attestation wording will more closely align with CMS requirements and will allow plans to answer this attestation with a “yes” without having to qualify their response."]
["Part C, MA Application, Appendix I, SNPs"]
["Part C, MA, Appendix I, SNP","6","93","Under the \"D-SNP State Medicaid Agency(ies) Contract(s)\" category, it is unclear what to submit in the following situations: \n\n1.   A State Medicaid Agency contract that is already effective for the application year, but has not yet been amended to reflect the application year's service area.\n\n2.  A State Medicaid Agency contract that is currently effective for the year prior to the application year, but the agreement has not been amended or a new contract signed to establish the relationship for the application year.   \n\nIn each of these cases, it would help to know whether CMS wants applicants to complete the D-SNP upload document or submit the existing State Medicaid Agency contract.   ","To help draw a clear line on what to do in situations where onlytechnical updates are needed to the State Medicaid Agencies category, we recommend inserting under Section 6, Attestation, State Medicaid Contract, Item 1, the following sentence:\n\n(Note:  If an updated contract or contract amendment will be needed for the application year, applicant should go to question #3.) "]
["Part C, MA, Appendix I, SNP","11","98","Under the \"Staff Structure and Care Management Roles\" category, there are several items that are general health plan operational items not unique to SNPs (e.g., process enrollment, verify eligibility, or process claims).  ","We recommend removing the attestations of general operational duties that are applicable to all types of plans so the \"Staff Structure and Care Management Roles\" are more focused on items applicable to SNP plans.  "]
["Part C, MA, Appendix I, SNP","11","98","The \"Staff Structure and Care Management Roles\" category, item #24 (\"Assures maintenance and sharing of healthcare records\") is not clear and could be interpreted to mean that staff and resources are required to assure maintenance of health care records by network providers, which providers are required to do through participation agreements.   ","We recommend revising item #24 to read \"Assures sharing of health care information as appropriate.\" "]
["Part C, MA, Appendix I, SNP","11","99","The \"Staff Structure and Care Management Roles\" category, item #41 (\"Conducts medical chart reviews\") is not clear and could be interpreted as a comprehensive medical chart review.  Further, chart reviews are only regularly done at time of discharge from a facility.   Otherwise, targeted medical chart reviews are done as needed.   ","We recommend revising item #41 to read \"Conducts appropriate medical chart review as needed.\""]
["Part C, MA, Appendix I, SNP","11","100","\"Provider Network and Use of Clinical Practice Guidelines\" category, item #1 (\"Applicant has a network of providers and facilities having specialized clinical expertise pertinent to the targeted special needs population.  The provider network includes:\")   Confusion has arisen on this item as reviewers have interpreted this to mean that the plan employs all of the individuals with the required level clinical expertise.  However, health plans can provide access to specialized clinical expertise for the targeted special needs population through employed, contracted or vendor relationships with clinicians.   \n\n","We recommend modifying this language to make it more consistent with 42 CFR 422.101(f)(2)(ii) that requires SNPs to \"[h]ave appropriate staff (employed, contracted, or non-contracted) trained on the SNP model of care to coordinate and/or deliver all services and benefits.  For example, revise #1 to read \"Applicant provides access through contracted or employed relationships to a network of providers and facilities having specialized clinical expertise pertinent to the targeted special needs population.  The provider network includes:...\"    "]
["Part C, MA, Appendix I, SNP","11","100","\"Provider Network and Use of Clinical Practice Guidelines\" category, item #18 (\"Applicant assures that the provider and facility network having specialized clinical expertise pertinent to the targeted special needs population delivers services. Specific services include:...:\").  Reviewers of this item believe the SNP should have providers that only see members of the targeted special needs population.  However, plans create and leverage provider networks that can service both the SNP population as well as the broader Medicare Advantage population. Having a broad network of contracted providers does not diminish the clinical expertise of the network to meet the needs of the targeted population.  Rather, having a broad newtwork of physicians - particulary providers who may not otherwise normally agree to see the targeted population (i.e. dual-eligibles) - provides beneficiaries with expanded access and choice.  We believe this should be encouraged by CMS.  \n\n","We recommend revising #18 to read \"Applicant provides access through contracted or employed relationships to a network of providers and facililties having specialized clinical expertise pertinent to the targeted special needs population.  The provider network includes:.\"    "]
["Part C, MA, Appendix I, SNP","11","101","\"Provider Network and Use of Clinical Practice Guidelines\" category, item #45 (\"45. Applicant has the beneficiary notify the plan and/or interdisciplinary team regarding necessary services\").  In this section, it is not clear whether SNPs are being directed to have members contact the plan each time they want a service or only in cases when they are having trouble obtaining needed services.  If the intent is to require members of SNPs to contact the plan each time \"regarding necessary services,\" this will cause member confusion as this may be seen as a prior authorization requirement and may inadvertently reduce access for members that are reluctant to make such calls to their health plan.  Further, plan's can only require prior authorization to the extent this is reflected in the bid filing.  Finally, beneficiary compliance is beyond the plan's control.  If this item is intended to require plans to make available a means for members to call into a plan for assistance in obtaining necessary services, we believe it should be restated.   ","We recommend deleting item #45 because the scope is too broad.  In the alternative, we recommend item #45  be revised to read:  \"Applicant provides a means for beneficiaries to notify the plan and/or interdisciplinary team regarding services the beneficiary feels are necessary.\" "]
["Part C, MA, Appendix I, SNP","11","102","\"Provider Network and Use of Clinical Practice Guidelines\" category, item #52 requires notification to the interdisciplinary care team and respective providers when transitions of care occur, however, it is not always necessary to notify all members of the interdisciplinary care team.","We recommend revising #52 to read \"Applicant has written procedures that require notification to appropriate members of the interdisciplinary care team and providers when transitions of care occur.\"    "]
["Part C, MA, Appendix I, SNP","11","102","Under the \"Provider Network and Use of Clinical Practice Guidelines\" category, item #54 (\"Applicant disseminates the results of the transition of care analysis to the interdisciplinary care team.\"), there is concern that some providers will serve a very small number of SNP members and it will be difficult for them to give us updates on care transitions, which may impact transition of care analysis. ","We recommend revising #54 to read \"Applicant analyzes transitions of care and identifies area of improvement to meet member needs as appropriate.\"   With these changes, this item may fit better with the quality improvement sections of the application.  "]
["Part C, MA, Appendix I, SNP","11","104","There are two categories labeled \"Health Risk Assessment.\"   We believe the 2nd category labeled \"Health Risk Assessment\" was intended to be labeled \"Communication,\" as it was labeled in year's application.      ","We suggest revising the category \"Health Risk Assessment\" found on page 104 to \"Communication.\"  "]
["Part C, MA, Appendix I, SNP","11","105","\"Care Management for the Most Vulnerable Subpopulations\" category, item #2 (\"Applicant delineated additional services it will provide for its most vulnerable beneficiaries.  These add-on services address the specialized needs of the following vulnerable special needs individuals within each target population\").  The term \"additional services\" can mean items in the Plan Benefit Package and items in the PBP are to be available to all members of the plan, not just the most vulnerable.  However, care management services are designed to change based on the member's specific conditions. "," We recommend changing \"additional services\" to \"care management services\" to clarify what we believe is the CMS intent of this attestation. "]
["Part C, MA, Appendix I, SNP","11","106","Under the \"Performance and Health Outcome Measurement\" category, item #29 (\"Applicant communicates the results of its model of care evaluation to all stakeholders\"), what is meant by stakeholders?  If stakeholders is defined too broadly, the audience will be too large resulting in little benefit from the communication.","We recommend revising \"all stakeholders\" to \"all appropriate internal and external stakeholders.\""]
["Part C, MA, Appendix I, SNP","14 & 15","109 - 112","It is not clear whether Section 14 or 15, or both, should be completed by applicants.  If an applicant has a State Medicaid Agency contract currently in place but requiring technical changes such as an extension to cover the application year or an amendment to reflect the service area for the application year, should the applicant consider the application complete if Section #14 is completed and skip #15?  ","Please clarify that Section 14 is to be completed if contract negotiations are in progress or if technical amendments to the existing contract will be needed for the application year and Section 15 is to be completed if the State Medicaid Contract has already been signed.   Further, please clarify that applicants need only complete section 14 or 15 as appropriate.  "]
["Part C, MA, Appendix I, SNP","14","110-111","Under the 2011 D-SNP State Medicaid Agency Contract upload document, item #7, the Note states \"The description must contain language indicating that the MA SNP has written procedures for ensuring Medicaid network adequacy including access standards.\"  The applicability of Medicaid network adequacy standards is confusing if the State Medicaid Agency Contract only provides for the coordination of Medicaid services and not the actual provision of services.  If SNPs are not actually providing Medicaid services, imposing a network adequacy requirement other than what is already required by CMS is unnecessary and impractical.  For example, a SNP would not contract with a home health agency for Medicaid-only personal care services if the SNP is not providing such services under its CMS and/or State contract.  ","Please clarify in the Note for item #7 that this item is only applicable if the State Medicaid Agency contract requires the D-SNP to provide Medicaid services.  "]
["Part C, MA, Appendix I, SNP","16","113-114","The I-SNP Upload documents is not clear with reference to the following items:\n\n(1)  Consistency is needed as to whether Medicaid and/or Medicare numbers of LTC or ALF facilities.  As an example, in one portion of the upload document, both the Medicare and Medicaid number is requested for LTC facilities. \n\n(2)  Some ALFs do not have Medicare or Medicaid provider numbers.\n\n(3)  It is unclear whether the upload document is asking for a list of ALFs that the MAO intends to contact with or already has a contract. On page 96, Section 9, Items #2 and #3  indicate that the ALFs need to be under contract, but the upload document is not clear on this requirement, which is confusing.  ","(1) Please clarify whether the Medicaid or Medicare number is needed for LTC facilities.  \n\n(2) We recommend removing or making optional, the field for Provider # since some ALFs do not have Medicaid or Medicare provider numbers.\n\n(3) We recommend revising the upload document to state \"Provide a list of contracted assisted-living facilities\" similar to the wording used in the form and attestation for LTCs if that is the intent."]
["HSD Tables"]
["Part C - Signature Page Form (Form referenced but not provided)","3.9","32","Applicants are required to provide a template of provider signatures when the HSD tables already contain this required information.   We believe that providing the signature page form is duplicative of information that organizations are already required to provide.  We wish to avoid duplication since signature pages have been collected using existing HSD tables or data is also found on existing HSD tables.","The form used in 2011 had several fields requesting information already on the HSD tables:  Name of Physician/Provider and Type (MA Provider/Facility Tables), Contract Template Type (MA Contract and Signature Index - Provide/Facilities), Contract Signature Name (MA Signature Authority Grid), and a field for Contract Signature Date when this is on the signature page itself.  We recommend that the Signature Page Form requirement be eliminated."]
["Part C - HSD Tables","HSD Instructions","14","CMS includes a limited exception list.  As a result, there is concern that reasons other than those listed will NOT be allowed by CMS.","We recommend that the option, \"Other\", be included in the event that there are exception reasons that do not fit into those listed or there are multiple reasons for exceptions.  Examples of exceptions not listed:   providers are resistant to managed care contracting or won't accept 100% of Medicare allowable, etc."]
["Part C - HSD Tables","HSD Instructions","4-7","CMS has required additional information on the HSD tables which is not readily available for use in an automated fashion. For instance, the number of Medicare-certified beds for hospitals and SNFs and ICUs and MH/SA facilities is not readily available to MCOs.  This is also true of Medicare certification numbers.  ","While we understand the need for certain data to evaluate adequacy using the Automated Criteria Check we request assistance in obtaining such data.  We would continue to ask that CMS provide certain information downloadable in excel or other data files that will assist plans in their automated production of HSD tables and population of these fields with accurate CMS information.  For example a listing of  Medicare Certified Providers with their MCNs and Certified Bed Counts would be helpful, .e.g. Hospitals, SNF, HHA, CORFs, etc.   Manual lookup on medicare.gov is cumbersome and not all required data is available there.  "]
["Part C - HSD Tables","HSD Instructions","9","HSD2A is not included in the HSD tables provided in the draft sample, but referred to in instructions.","We request clarification as to whether CMS intends to require both tables as part of the 2012 applications.  If so, MCOs need to understand whether there will be any changes to these tables."]
["Part C - HSD Tables","HSD Instructions","11-12","The HSD-4 Table for Part C refers to outpatient drugs; however the Part D application requires information related to the Rx network.  Being required to provide this information in the Part C application is duplicative of information required in the Part D application.","We recommend that this column be removed from the HSD-4 since this information is already included in the Part D application."]
["Part C-HSD Tables","HSD Instructions","All","Historically, the final version of the HSD tables has not been released until January.","While it is recognized and appreciated that CMS has provided the draft application earlier this year, it is requested that the final HSD Tables be made available by November or December 1 rather than with the release of the Final Application in early January. This would allow organizations with a high volume of submissions additional time to train network personnel and sufficient time to upgrade HSD tools, excel formulas, etc. on any changes made to the tables. \n\n"]
["Part C-HSD Tables","HSD Instructions","2","Cardiology is identified with Specialty Code of 009 and Cardiac Surgery with 008.  Based upon CMS network adequacy reporting, these codes are transposed as they were in 2011 Instructions.","We recommend CMS review and revise 2012 HSD Instructions to display correct specialty coding as needed.  Codes used on tables and by Automated Criteria Check must be in sync.  Last year, CMS corrected to show 008 for Cardiology and 009 for Cardiac Surgery. "]
["Part C-HSD Tables","HSD Instructions","All","Document revisions are not dated in a naming convention such that plans would know that those downloaded from HPMS are the same or are updated versions of those that were posted on CMS website.\n\n","We recommend CMS use the same naming conventions and utilize dates for files in HPMS and on the website so plans can easily identify the files that are updated.  "]
["Part C-HSD Tables","HSD Instructions","5, 8","CMS instructions are not explicit enough in the address and provider name requirements regarding use of commas, \"&\" signs, suite #s, etc.","We recommend CMS provide more explicit instructions/guidelines so that HPMS uploads do not result in a fail due to an address deficiency or an improper naming convention (i.e. an \"&\" sign)."]