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Medicare Information & Policies

Medicare Information and Policies

The Centers for Medicare and Medicaid Services (CMS) requires that Health Net operate in compliance with CMS regulations and report any issues that may be out of compliance. Therefore, Health Net requires that all Medicare Advantage (MA) first-tier, downstream and related entities (FDRs) report any issues that may be considered out of compliance to their Health Net business contact immediately upon learning of the incident. In addition, FDRs may report potential issues that may be considered out of compliance to Health Net as follows:

  • Health Net Medicare Compliance Officer
    Donovan Ayers
    21650 Oxnard Street, Mail Stop: CA-102-24-23
    Woodland Hills, CA 91367
  • You can also report via;
    • Fraud, Waste & Abuse Helpline: 1-866-685-8664
    • Ethics & Compliance Helpline: 1-800-345-1642

All Health Net first-tier providers (those who hold a direct contract with Health Net) and downstream providers (entities with which a first-tier entity contracts to provide services to MA members) and first-tier and downstream employees must complete this training. First-tier entities are responsible for their downstream entities' completion of the training. Training must be completed annually by December 31 and must also be a part of orientation for new employees. This is subject to audit upon request from Health Net. This process is not related to and is separate from any provider appeals and grievance processes.

First-tier entities may download and distribute this training to their downstream providers.

Documentation Retention

Once a first-tier entity has completed the training, no further action is required. There are no acknowledgment or attestation forms to be returned to Health Net. First-tier entities must have documentation that the training was distributed to all of its employees and downstream entities and employees, as applicable, readily available for audit upon request from Health Net in the form of a mailing list, fax list or other equivalent format. Downstream entities do not need to submit acknowledgment or attestation forms to first-tier providers. Policies and procedures should also reflect inclusion of the training in new employee orientation processes. 

Occasionally, the Centers for Medicare and Medicaid Services (CMS) will make mid-year changes to Original Medicare. These are known as National Coverage Determinations (NCDs).

Newly Required Preventive Services

The following preventive services are covered without cost-share, retroactive to October 14, 2011, according to the CMS' National Coverage Determination (NCD):

  • Screening and behavioral counseling interventions in primary care to reduce alcohol misuse
  • Screening for depression in adults in a primary care setting

The following preventive services are covered without cost-share, retroactive to November 8, 2011, according to the CMS' NCD:

  • Screening for sexually transmitted infections (STIs)
  • High-intensity behavioral counseling to prevent STIs

The following preventive services are covered without cost-share, retroactive to November 29, 2011, according to the CMS' NCD:

  • Screening for obesity and counseling for eligible beneficiaries by primary care providers

Additional Information

If you have questions regarding this information, refer to CMS' Web sites at CMS Coverage Email Updates and News and Announcements and select the applicable CMS press release. For all other questions, contact the applicable Health Net Provider Services Center.

The Centers for Medicare and Medicaid Services (CMS) require contractors and their First Tier Downstream and Related entities (FDRs) to monitor federal exclusions lists. The parties/entities on these lists are excluded from various activities, including rendering services to Medicare enrollees (unless in the case of an emergency, 42 CFR § 1001.1901) and from being employed or contracted to render services to Medicare enrollees. Health Net requires that its participating physician groups (PPGs), hospitals, ancillary providers, and physicians continuously monitor federal exclusion lists. The information below provides the names of each federal exclusion list, governing regulations and CMS guidance, including links to publically available exclusion lists.

HEALTH NET AND FDR HIRING AND CONTRACING RESPONSIBILITIES

Health Net and their First Tier Downstream and Related entities (FDRs) are required to monitor federal exclusion lists to ensure that Health Net and their First Tier Downstream and Related entities (FDRs) are not hiring, contracting or paying excluded parties or entities for services rendered to enrollees in Health Net’s MA and MA-PD plans. MAOs and their FDRs must check the List of Excluded Individuals and Entities (LEIE) and Exclusions Extract Data Package (EEDP) federal exclusion lists prior to hiring or contracting with any new employee, temporary employee, volunteer, consultant, governing body member, or FDR for Part C- and Part D related activities. MAOs and their FDRs must continuously monitor these lists at least monthly to ensure parties or entities that were previously screened have not become excluded later.

List of Excluded Individuals and Entities (LEIE)

The Office of the Inspector General -- Health and Human Services, (OIG-HHS) imposes exclusions under the authority of sections 1128 and 1156 of the Social Security Act.

Exclusions Extract Data Package (EEDP) 

The General Services Administration (GSA’s) EEDP is a government-wide compilation of various federal agency exclusions, and replaces the Excluded Parties List System (EPLS). Exclusions contained in the EEDP are governed by each agency’s regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion databases. All parties or entities listed on the EEDP are subject to exclusion from Medicare participation.

  • The current EEDP is available on the SAM website at: www.sam.gov, with additional information located under Help > User Guides > Quick User Guides > Helpful Hints for Public Users.

HEALTH NET AND FDR PAYMENT RESPONSIBILITIES

Health Net and their First Tier Downstream and Related entities (FDRs): PPGs, hospitals, and ancillary providers cannot pay participating and non-participating parties or entities included on these lists for any services using federal funds, except as documented in the CMS Internet Only Manual, publication 100-16, Chapter 6 -- Relationships with Providers, which states, ‘‘The OIG has a limited exception that permits payment for emergency services provided by excluded providers under certain circumstances. See 42 CFR § 1001.1901.’’ FDRs contracting with Health Net and their First Tier Downstream and Related entities (FDRs) must have a documented process in place to ensure compliance with these guidelines, and notify enrollees who obtain services from excluded parties and make claims payments as allowed under these exceptions. This documentation is subject to audit upon request from Health Net or CMS.

GOVERNING REGULATION AND CMS GUIDANCE 

The names of parties that have been excluded from Medicare participation are published in the Office of the Inspector General U.S. Department of Health and Human Services (OIGHHS) List of Excluded Individuals and Entities (LEIE), and on the General Services Administration’s (GSA) Exclusions Extract Data Package (EEDP) (or Excluded Parties List System (EPLS), which was replaced by the EEDP), as referenced through the System for Award Management (SAM) website at ww.sam.gov. Medicare Advantage organizations (MAOs) and their FDRs must abide by the regulations documented in the Social Security Act 1862(e)(1)(B), 42 CFR §422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6), and 1001.1901. These federal exclusion requirements are further interpreted and communicated as guidance by CMS in Medicare Manual, Volume 100-16, Chapters 9 and 21 §50.6.8. Additional regulations that require sponsors to include CMS requirements in their contracts, as well as monitor their FDRs, are available in 42 CFR §422.504(i)(4)(B)(v) and 423.505(i)(3)(v).