Response to Comments

2017 Consolidated 60-day comments for Part C Application
Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

1

America's
60 day
Health
Insurance Plan

Instructions

2.7 Types of Applications 17
-Service Area Expansion
Applications

Service Area Expansion (SAE)applications
will require Health Service Delivery (HSD)
Tables for the entire network not just the
counties that an applicant is proposing to
expand into with the SAE request.



As a result of CMS’ proposed requirement,
the number of counties for which SAE
applicants would be required to submit
HSD Tables could increase dramatically.
For example, a plan with an existing service
area that covers 50 counties that is seeking
to expand into 2 additional counties would
be required to submit HSD Tables for 52
counties instead of just 2. This is extremely
problematic because we understand that
HSD Table submissions require
preparation, review, and transmittal of large
volumes of data tables into the Health Plan
Management System (HPMS) through a
time-intensive, manual process that requires
substantial MA organization resources.

Deletion

Reject. CMS has an expectation that MAOs are
routinely monitoring their networks to confirm
that networks are in compliance with the current
network adequacy standards. Therefore, the
requirement to upload HSD tables for the entire
network at the contract level with a SAE
application submission is consistent with CMS’s
expectations that MAOs are meeting network
standards.

2

America's
60 day
Health
Insurance Plan

Instructions

2.7 Types of Applications 17
-Service Area Expansion
Applications

Request delay in implementation of SAE
To ensure the most cost-effective process
requirement for MAO with large networks possible, we believe SAE applicants —
beyond the CY 2017 application year
particularly those with large existing service
areas — require adequate time before the
implementation of such a new requirement
to explore how they could most efficiently
submit large amounts of network data
across multiple service areas and to
consider and implement changes to their
processes and systems. Accordingly, if
CMS decides to expand its HSD submission
requirement, we urge the agency to delay
implementation of any new requirement
beyond the CY 2017 application year.

Revision

Reject. CMS has an expectation that MAOs are
routinely monitoring their networks to confirm
that networks are in compliance with the current
network adequacy standards. Therefore, the
requirement to upload HSD tables for the entire
network at the contract level with a SAE
application submission is consistent with CMS’s
expectations that MAOs are meeting network
standards.

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

3

Kaiser
Permanente

60 day

Instructions

2.7 Types of Applications-17
Service Area Expansion
Applications

Service Area Expansion (SAE)applications
will require Health Service Delivery (HSD)
Tables for the entire network not just the
counties that an applicant is proposing to
expand into with the SAE request.



We believe this requirement is
unnecessarily burdensome for the plan
sponsors and would not provide CMS with
any additional information related to the
purpose of the application – i.e., the
expansion of the MAO into a particular
county or counties. It would be very time
consuming for an MAO to submit HSD
tables for an entire network while at the
same time collecting the data and
information required for the 132 page Part
C (and 143 page Part D) SAE application
itself. We believe that the better process for
CMS to use to monitor network adequacy is
to include network adequacy as part of a
regular audit schedule for MAOs rather than
piggy-backing on the SAE application.

Deletion

Reject. CMS has an expectation that MAOs are
routinely monitoring their networks to confirm
that networks are in compliance with the current
network adequacy standards. Therefore, the
requirement to upload HSD tables for the entire
network at the contract level with a SAE
application submission is consistent with CMS’s
expectations that MAOs are meeting network
standards.

4

Kaiser
Permanente

60 day

Instructions

2.7 Types of Applications-17
Service Area Expansion
Applications

What is the intended impact/ramifications
to MAOs related to the SAE change?

It is unclear what the ramifications of such
review by CMS would be as it relates to the
SAE itself. For example, would CMS deny
the MAO’s application for the SAE even if
it met the access standards in the SAE
county but happened not to meet one of the
standards in an unrelated geographic area?
Would the MAO have the opportunity to
correct any deficiencies in non-SAE
counties separately from the application for
the SAE if it met network adequacy in the
SAE county? If CMS imposes the
requirement of concurrent submission of the
HSD tables for the entire network, we
recommend that CMS bifurcate the review
of the SAE from the review of the network
itself and address any deficiencies
separately from the approval of the SAE
application.

Insertion

Clarify. CMS is developing the process to
implement the SAE application change.
Additional information will be provided to the
industry prior to the CY 2017 application cycle.

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

5

United
Healthcare

60 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Due Dates for 1.8 Due Dates for
12
Application Applications – Medicare
Advantage and Medicare
Cost Plans

Timeline for CMS Application, forms and
HSD Instructions are problematic for this
organization as the timeline does not allow
for the volume of HSD table submissions
anticipated with the SAE application
change.

Comments & Recommendation(s) from
Source

We respectfully ask that CMS provide HSD
criteria and final instruction/forms earlier in
the process, with an October timetable
being optimal. Last year, the final CMS
Application, forms, and HSD instructions
were issued on January 14, 2015 with
applications due February 18, 2015. As a
high volume HSD table submitter, this
timeline is extremely problematic for our
organization. In order to develop HSD
Tables by the CMS deadline, UHC begins
to build them well in advance of the CMS
deadline and has tables largely built by
early December, several weeks before the
date that final application information is
made available by CMS. As a result, this
requires revising/repeating work and could
also require programming changes that are
difficult to accomplish in advance of the
CMS application deadline.

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)
Revision

Clarify. CMS will accommodate the review of
additional counties within the annual application
cycle.

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

6

United
Healthcare

60 day

Instructions

2.7 Types of Applications 17
-Service Area Expansion
Applications

Service Area Expansion (SAE)applications
will require Health Service Delivery (HSD)
Tables for the entire network not just the
counties that an applicant is proposing to
expand into with the SAE request.



We strongly recommend that CMS omit this
new requirement from the CMS Application
process. It is unduly burdensome to require
that MAOs complete HSD Tables for the
entire existing MAO contract service area in
addition to those counties included in the
expansion application. We believe that this
new requirement will have the unintended
result of MAOs not expanding into new
service areas, thereby reducing the number
of MAO choices available to Medicare
beneficiaries. The purpose of submitting
HSD Tables to CMS during the application
process is to demonstrate to CMS the
MAO's ability to meet CMS network
adequacy standards for the service areas in
which the MAO is proposing to expand. We
believe that this new requirement goes
beyond the intent of the expansion
application process.

Deletion

Reject. CMS has an expectation that MAOs are
routinely monitoring their networks to confirm
that networks are in compliance with the current
network adequacy standards. Therefore, the
requirement to upload HSD tables for the entire
network at the contract level with a SAE
application submission is consistent with CMS’s
expectations that MAOs are meeting network
standards.

7

United
Healthcare

60day

CMS State
Certification
Form

4.4 CMS State
Certification Form

Request deletion of question #3 which
requests from the applicant to identify the
type of application filed with CMS. The
applicant is required to circle all of the
appropriate types which include: HMO,
PPO, MSA, PFFS and Religious/Fraternal.

We recommend CMS amend the state
certification form to delete question 3.
Specifically, the nomenclature creates
confusion for states that use different
terminology for benefit plans. For example,
a state may use the terms “closed panel” to
describe products, rather than the term
“HMO.” From a state’s perspective, an
HMO is typically a type of entity license.
The certification form is effective without
the question in that the state’s obligation is
to certify that the applying entity is licensed
and solvent. Alternatively, regulatory
changes could be made to describe the
products more broadly to improve the
alignment with the terminology used by the
states.

Deletion

Reject. The current language will be maintained in
the CMS State Certification form.

65-66

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

8

United
Healthcare

60day

HSD
Instructions

MA Provider Table Columns Explanations

8

9

United
Healthcare

60day

HSD
Instructions

10

United
Healthcare

60day

HSD
Instructions

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

Delete references to Column N We recommend that the HSD Instructions
Employment Status from section - Contract be revised to omit the explanation and
Type descriptions because CMS deleted
reference to the Employment Status column
Employment Status from the MA Provider under this section.
HSD tables.

Deletion

Accept. CMS will delete references to column NEmployment status as it has been deleted from the
MA Provider HSD table.

Transplant Facilities List
Format

Request for CMS to provide transplant
facilities list in file format such as .txt or
Excel/Access format instead of PDF file

Revision

Reject. The MAO has identified that the file is
only provided in a PDF format. We are unable to
confirm that another file format can be made
available for this document.

Facility Table Services –
Access to CMS
Information

Request for CMS to automate data that is
CMS often requires information that is not
requested on HSD MA Facility tables such readily available for use in an automated
as Medicare certified beds for hospitals.
fashion. For example, the number of
Medicare certified beds for hospitals,
skilled nursing facilities, intensive care
units, and inpatient psychiatric facilities is
not readily available to managed care
organizations (MCO). We request that CMS
provide information so that it is
downloadable in Excel or other data
formats. This will assist plans in their
automated production of HSD tables and
population of these fields with accurate
CMS information. For example, CMS could
provide a resource from which MCOs can
obtain bed counts, by hospital location, so
that this information is consistent and
available to all health plans.

Revision

Reject: We would suggest that MAOs identify
sources for obtaining and confirming this
information such as facility websites. No
government data base is going to be as current and
up to date as the facility's own official record in
the CEO or CFO's office.

UHC appreciates CMS’s inclusion of a
downloadable certified transplant facilities
list. However, the list is currently only
available in a PDF format, which requires
considerable manual manipulation to
convert to Microsoft Excel or Access for
automated reporting. We request that CMS
produce the certified transplant list in a .txt
or Excel/Access format similar to the other
website posted downloadable files of CMS
certified providers (e.g., Hospital, Home
Health, Suppliers) in order to streamline
this process and eliminate the need for
manual manipulation.

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

11

United
Healthcare

60day

HSD
Instructions

Facility Table Services –
Inaccurate Information
on Medicare Website

12

United
Healthcare

60 day

HSD
Instructions

Appendix A – CY 2017
HSD Submission
Frequently Asked
Questions

Application Page Description of the Issue or Question
Number

13

Comments & Recommendation(s) from
Source

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

Inaccuracy of data regarding facility
services identified on Medicare.gov

Through our research, we have noticed that
Medicare’s website often lists services
available at an acute inpatient hospital even
though the hospital operating certificate
may not be approved by Department of
Health to provide those services.
Additionally, it appears that hospitals can
remain on these lists even after the hospital
confirms that it does not actually provide
those services. This is especially
problematic when these providers are being
considered by CMS to determine MAO
network adequacy and accessibility or when
a network exception is being requested by a
MAO. We ask that CMS not utilize the
Medicare.gov website when the data has
been verified by the MAO as being
inaccurate or that CMS clarify how to best
address the situation when a service or
provider is incorrectly posted to
Medicare.gov as being a Medicare
participating provider.

Revision

Clarify- Medicare.gov information is not the sole
source of information about the Medicare status of
individual services or components operated by a
hospital. MAOs are encouraged to identify other
resources that are currently utilized within the
industry.

Request for Automated Criteria Checks
(ACC) be available on demand instead of
scheduled pre-checks for HSD tables

Appendix A of the HSD Instructions for CY
2017 Applications states that HSD prechecks are only allowed on specific dates
and times, Thursdays by 8:00pm ET. Since
Automated Criteria Checks (ACC) are
automated, we request that CMS create an
open window for on-demand pre-checks in
lieu of date/time specific limitations. This
would allow table editing work to remain
more fluid and timely.

Revision

Clarify. CMS is developing the process to
implement the SAE application change.
Additional information will be provided to the
industry prior to the CY 2017 application cycle

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

13

United
Healthcare

60day

14

United
Healthcare

15

United
Healthcare

Application Section
(Number/ Header)

Application Page Description of the Issue or Question
Number

Comments & Recommendation(s) from
Source

HSD
Exception
Request
Template

3

Duplicative and Redundant language
regarding the listing of contracted
providers/facilities on the Exception request
template

The Exception form currently reads, “List
the contracted providers/facility that will
ensure access (they must be listed in the
HSD Table under the country in which they
are providing services). Also, list the closest
contracted provider/facility of the specialty
code type.” UHC believes that this
requirement for health plans to list the
contracted providers/facilities "that will
ensure access" is both duplicative and
redundant as this information is already
listed on the HSD table. For that reason, we
suggest that the Exception form be edited to
read “List the closest contracted
provider/facility of the specialty code type.”

Revision

Accept with Modification: CMS is considering
revisions to the Exception Request template.

60day

MA Provider N/A
HSD Table

N/A

Request to remove the column M - CMS
Model MA Contract from the table and
correspondence HSD instructions

The MA Provider table has the required
data element of "Uses CMS MA Contract
Amendment? Y for yes, N for no." We
believe that this is unnecessary as this is
already addressed as an attestation. Since
this included in the attestation, we request
that CMS remove this question from the
HSD tables.

Deletion

Reject. CMS will maintain the current format of
the MA Provider HSD Table.

60day

MA Facility
HSD Table

N/A

Request to remove the column L - CMS
Model MA Contract from the table and
correspondence HSD instructions

The MA Facility table has the required data
element of "Uses CMS MA Contract
Amendment? Y for yes, N for no." We
believe that this is unnecessary as this is
already addressed as an attestation. Since
this included in the attestation, we request
that CMS remove this question from the
HSD tables.

Deletion

Reject. CMS will maintain the current format of
the MA Facility HSD Table.

N/A

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)

Comment
Number

Source of
Comment:
(Company
Name)

2017 MA Application
Application Part
60 day or
30 day

Application Section
(Number/ Header)

16

Health Care
Service
Corporation

60day

2.7 Types of Applications 17
-Service Area Expansion
Applications

Instructions

Application Page Description of the Issue or Question
Number

Service Area Expansion (SAE)applications
will require Health Service Delivery (HSD)
Tables for the entire network not just the
counties that an applicant is proposing to
expand into with the SAE request.



Comments & Recommendation(s) from
Source

Completion and review of the HSD tables,
as well as the required accompanying
exceptions process when providers are not
available in certain areas, entails substantial
time and effort for the applicant and for
CMS reviewers. We are concerned about
the additional time and effort for applicants
and CMS that this proposed
requirement would entail and suggest that
CMS not move forward with the
requirement. If CMS
does decide to implement the requirement
despite these concerns, we recommend that
for SAEs in contracts that include more
than one state, CMS limit the HSD
submission to only the state in which the
expansion is proposed.

Type of Suggestion CMS Decision (Accept, Accept with
(Insertion Deletion, Modification, Reject, Clarify)
or Revision)
Deletion

Reject. CMS has an expectation that MAOs are
routinely monitoring their networks to confirm
that networks are in compliance with the current
network adequacy standards. Therefore, the
requirement to upload HSD tables for the entire
network at the contract level with a SAE
application submission is consistent with CMS’s
expectations that MAOs are meeting network
standards.