Provider Participation in BCBSGA’s MA Plans Participation Procedures for Physicians and Physician Group(s) BCBSGA’s MA plans must provide for the participation of individual health care professionals through reasonable procedures that include: (a) Written notice of rules of participation (b) Written notice of material changes in participation rules before they become effective (c) Written notice of adverse participation changes, and (d) Process for appealing adverse physician participation decisions.Last update April 2, 2012 8 (These requirements also apply to physicians that are part of a subcontracted network.) In addition, PROVIDER agrees that in no event, including but not limited to non-payment by Plan, insolvency of the Plan or breach of their Agreement, shall the PROVIDER bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Covered Individual or persons other than the Plan acting on their behalf for Covered Services provided pursuant to their Agreement.
This provision does not prohibit the collection of supplemental charges or Cost Shares on the Plan’s behalf made in accordance with the terms of the Covered Individual’s Health Benefit Plan or amounts due for services that have been correctly identified in advance as a non-Covered service, subject to medical coverage criteria, with appropriate disclosure to the Covered Individual of their financial obligation. This advance notice does not apply to services not covered due to a statutory exclusion from the Medicare Advantage Program. PROVIDER further agrees that for Covered Individuals who are dual eligible enrollees for Medicare and Medicaid, that PROVIDER will ensure they will not bill the Covered Individual for Cost Sharing that is not the Covered Individual’s responsibility and such Covered Individuals will not be held liable for Medicare Parts A and B Cost Sharing when the State is liable for the Cost Sharing. In addition, PROVIDER agrees to accept the Plan payment as payment in full or by billing the appropriate State source.
Terminating Participation with BCBSGA’s Medicare Advantage Plans In the event a provider wishes to terminate his/her participation in either of BCBSGA’s Medicare Advantage networks or BCBSGA terminates a provider for reasons other than cause, a mandatory 60-day notification is required for the termination by either party. Please refer to your contract for specific termination requirements. Any provider requesting termination of his/her participation should send written notification to the BCBSGA Network Management Department in his/her region. Upon receipt of the termination request, BCBSGA will send a written, CMS-approved notification of the termination to all affected members at least 30 calendar days before the effective date of termination. MA organizations that suspend or terminate a contract due to deficiencies in the quality of care must give notice of that action to the licensing or disciplinary bodies. Termination of a Provider Contract with Cause A Medicare Advantage organization that suspends or terminates an agreement under which the health care professional provides service to the Medicare Advantage enrollees must give the affected provider written notice of the following:
• Reason for the action • Standards and the profiling data used to evaluate the health care professional when applicable • Mix of health care professionals the organization needs when applicable • Affected health care professional’s right to appeal the action and the process and timing for requesting a hearing. Last update April 2, 2012 9 The composition of the hearing panel must ensure that the vast majority of the panel members are peers of the affected health care professional. A Medicare Advantage organization that suspends or terminates a contract with a health care professional due to deficiencies in the quality of care must give written notice of that action to licensing, disciplinary, or other appropriate authorities. Termination of a Provider Contract without Cause Any provider requesting termination of his/her participation should send a written notification to the BCBSGA Network Management Department in his/her region. Upon receipt of the termination request, BCBSGA will send a written CMS-approved notification of the termination to all affected members at least 30 calendar days before the effective date of termination.
Provider Anti-discrimination Rules Plans are prohibited from discriminating with respect to reimbursement, participation or indemnification solely on the basis of a provider’s licensure or certification as long as the provider is acting within the scope of such licensure or certification. This prohibition does not preclude any of the following: • Refusal to grant participation to health care professionals in excess of the number necessary to meet the needs of enrollees; a Medicare Advantage (MA) plan may choose to contract with a doctor of medicine that meets the needs of enrollees and does not need to contract with another practitioner who can provide only a discrete subset of physician services. • Use of different reimbursement amounts for different specialties or within the same specialty • Implementation of measures designed to maintain quality and control costs consistent with the MA organization’s responsibilities. Compliance with Medicare Laws, Audits, and Record Retention Requirements Medical records and other health and enrollment information of an enrollee must be handled under established procedures that:
• Safeguard the privacy of any information that identifies a particular enrollee • Maintain such records and information in a manner that is accurate and timely • Identify when and to whom enrollee information may be disclosed. In addition to the obligation to safeguard the privacy of any information that identifies a particular enrollee, BCBSGA including its participating providers, is obligated to abide by all Federal and state laws regarding confidentiality and disclosure for mental health records, medical health records, and enrollee information. First tier and downstream providers must agree to comply with Medicare laws, regulations, and CMS instructions (422.504(I)(4)(v)), and agree to inspections, evaluations and audits by CMS and/or its designees and to cooperate, assist, and provide information as requested, and maintain records a minimum of 10 years;
For the purposes specified in this section, Providers agree to make available Provider’s premises, physical facilities and equipment, records relating to Plan’s Covered Individuals, including access to Provider’s computer and electronic systems and any additional relevant information that CMS may require. Providers acknowledge that failure to allow HHS, the Comptroller General or their designees the right to timely access under this section can subject Providers to a fifteen thousand dollar ($15,000) penalty for each day of failure to comply Types of MA Plans: (a) General rule. An MA plan may be a coordinated care plan, a combination of an MA MSA plan and a contribution into an MA MSA established in accordance with §422.262, or an MA private fee-for-service plan. (1) A coordinated care plan. A coordinated care plan is a plan that includes a network of providers that are under contract or arrangement with the organization to deliver the benefit package approved by CMS.
(i) The network is approved by CMS to ensure that all applicable requirements are met, including access and availability, service area, and quality. (ii) Coordinated care plans may include mechanisms to control utilization, such as referrals from a gatekeeper for an enrollee to receive services within the plan, and financial arrangements that offer incentives to providers to furnish high quality and cost-effective care. (iii) Coordinated care plans include plans offered by health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), regional or local preferred provider organizations (PPOs) as specified in paragraph (a)(1)(v) of this section, and other network plans (except PFFS plans). (iv) A specialized MA plan for special needs individuals (SNP) includes any type of coordinated care plan that meets CMS’SNP requirements and either— (A) Exclusively enrolls special needs individuals as defined in §422.2; or (B) Enrolls a greater proportion of special needs individuals than occur nationally in the Medicare population as defined by CMS.
(v) A PPO plan is a plan that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; provides for reimbursement for all covered benefits regardless of whether the benefits are provided within the network of providers; and, only for purposes of quality assurance requirements in §422.152(e), is offered by an organization that is not licensed or organized under State law as an HMO. (2) A combination of an MA MSA plan and a contribution into the MA MSA established in accordance with §422.262. (i) MA MSA plan means a plan that— (A) Pays at least for the services described in §422.101, after the enrollee has incurred countable expenses (as specified in the plan) equal in amount to the annual deductible specified in §422.103(d); and (B) Meets all other applicable requirements of this part.
(ii) MA MSA means a trust or custodial account— (A) That is established in conjunction with an MSA plan for the purpose of paying the qualified expenses of the account holder; and (B) Into which no deposits are made other than contributions by CMS under the MA program, or a trustee-to-trustee transfer or rollover from another MA MSA of the same account holder, in accordance with the requirements of sections 138 and 220 of the Internal Revenue Code. (3) MA private fee-for-service plan. An MA private fee-for-service plan is an MA plan that— (i) Pays providers of services at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk;
(ii) Does not vary the rates for a provider based on the utilization of that provider’s services; and (iii) Does not restrict enrollees’ choices among providers that are lawfully authorized to provide services and agree to accept the plan’s terms and conditions of payment. (b) Multiple plans. Under its contract, an MA organization may offer multiple plans, regardless of type, provided that the MA organization is licensed or approved under State law to provide those types of plans (or, in the case of a PSO plan, has received from CMS a waiver of the State licensing requirement). If an MA organization has received a waiver for the licensing requirement to offer a PSO plan, that waiver does not apply to the licensing requirement for any other type of MA plan.
(c) Rule for MA Plans’ Part D coverage. (1) Coordinated care plans. In order to offer an MA coordinated care plan in an area, the MA organization offering the coordinated care plan must offer qualified Part D coverage meeting the requirements in §423.104 of this chapter in that plan or in another MA plan in the same area. (2) MSAs. MA organizations offering MSA plans are not permitted to offer prescription drug coverage, other than that required under Parts A and B of Title XVIII of the Act. (3) Private Fee-For-Service. MA organizations offering private fee-for-service plans can choose to offer qualified Part D coverage meeting the requirements in §423.104 in that plan.