Oversight Framework Sample Clauses

Oversight Framework. Under the Demonstration, there will be a CMS-State Contract Management Team that will ensure access, quality, program integrity, and financial solvency, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the Commonwealth will require Participating Plans to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse. Participating Plans must have policies and procedures in place to identify and address fraud, waste, and abuse at both the Plan and the third-party levels in the delivery of Plan benefits, including prescription drugs, medical care, and long term services and supports. In addition, all Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to Demonstration Plans by CMS in the same way they are currently applied for PDP sponsors and Medicare Advantage organizations. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. Neither party shall take a unilateral enforcement action relating to day-to-day oversight without notifying the other party in advance. ● The Contract Management Team

Oversight Framework. Under the Demonstration, there will be a CMS-State Contract Management Team established to ensure access, quality, program integrity, financial solvency, and compliance with applicable laws, including but not limited to the Emergency Medical Treatment and Active Labor Act (EMTALA) and the ADA, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the State will require MSHO Plans to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse, with policies and procedures in place at both the plan and the third-party levels in the delivery of MSHO benefits, including prescription drugs, medical care, and long term services and supports. The Contract Management Team will also be responsible for addressing concerns that arise in the daily administration of the MSHO program that would result in reduced integration of the Medicare and Medicaid components of the program. In addition, all Part D requirements and Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to MSHO Plans by CMS in the same way they are currently applied for Prescription Drug Plan (PDP) sponsors and Medicare Advantage organizations. The Contract Management Team will be informed about these activities but will not take an active part in these ongoing projects or activities. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. The State may not take a unilateral enforcement action relating to day-to-day oversight without notifying CMS in advance. Both CMS and the State shall retain discretion to take immediate action where the health, safety or welfare of any Enrollee is imperiled or where significant financial risk is indicated. In such situations, Contract Management Team will undertake subsequent action and coordination.

Oversight Framework i. Under the Demonstration, there will be a CMS-State Contract Management Team that will ensure access, quality, program integrity, compliance with applicable laws, including but not limited to Emergency Medical Treatment and Active Labor Act (EMTALA) and ADA, and financial solvency, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the State will require FIDA Plans to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse. FIDA Plans must have policies and procedures in place to identify and address fraud, waste, and abuse at both the plan and the third-party levels in the delivery of FIDA Demonstration benefits, including prescription drugs, medical care, behavioral health, and community-based and facility-based LTSS. In addition, all Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to FIDA Plans by CMS in the same way they are currently applied for Prescription Drug Plan (PDP) sponsors and Medicare Advantage organizations. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. Neither party shall take a unilateral enforcement action relating to day-to-day oversight without notifying the other party in advance.

Oversight Framework. Under the Demonstration, there will be a CMS-State Contract Management Team that will ensure access, quality, program integrity, and financial solvency, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the Commonwealth will require Participating Plans to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse. Participating Plans must have policies and procedures in place to identify and address fraud, waste, and abuse at both the Plan and the third-party levels in the delivery of Plan benefits, including prescription drugs, medical care, and long term services and supports. In addition, all Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to Demonstration Plans by CMS in the same way they are currently applied for PDP sponsors and Medicare Advantage organizations. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. Neither party shall take a unilateral enforcement action relating to day-to-day oversight without notifying the other party in advance. Structure- The Contract Management Team will include representatives from CMS and the Commonwealth Medicaid agency, authorized and empowered to represent CMS and the Medicaid Agency about all aspects of the three-way contract. Generally, the CMS part of the team will include the State Lead from the Medicare Medicaid Coordination Office (MMCO), Regional Office Lead from the Consortium for Medicaid and Children’s Health Operations (CMCHO), and an Account Manager from the Consortium for Health Plan Operations (CMHPO). The precise makeup of each team will vary by state, and will include individuals who are knowledgeable about the full range of services and supports utilized by the target population, particularly long-term supports and services. Reporting - Data reporting to CMS and the Commonwealth will be coordinated and unified to the extent possible. Specific reporting requirements and processes will be detailed in the three-way contract. Quality (including HEDIS); core measures will be articulated in the MOU Rebalancing from Institutional to HCB...

Oversight Framework i. Under the Demonstration, there will be a CMS-State Contract Management Team that will ensure access, quality, program integrity, compliance with applicable laws, including but not limited to Emergency Medical Treatment and Active Labor Act (EMTALA) and ADA, and financial solvency, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the State will require STAR+PLUS MMPs to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse, including applicable requirements under Chapter 531 of Texas Government Code. STAR+PLUS MMPs must have policies and procedures in place to identify and address fraud, waste, and abuse at both the plan and the third- party levels in the delivery of covered services, including prescription drugs, medical and behavioral health services, and LTSS. In addition, all Medicare Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to STAR+PLUS MMPs by CMS in the same way they are currently applied for Medicare Advantage organizations and Part D sponsors. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. Neither party shall take a unilateral enforcement action relating to day-to-day oversight without notifying the other party in advance.

Oversight Framework i. Under the Demonstration, there will be a CMS-State Contract Management Team that will ensure access, quality, program integrity, compliance with applicable laws, including but not limited to Emergency Medical Treatment and Active Labor Act (EMTALA) and ADA, and financial solvency, including reviewing and acting on data and reports, conducting studies, and taking corrective action. CMS and the State will require ICDS Plans to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse. ICDS Plans must have policies and procedures in place to identify and address fraud, waste, and abuse at both the plan and the third-party levels in the delivery of ICDS benefits, including prescription drugs, medical care, and long term services and supports. In addition, all Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to ICDS Plans by CMS in the same way they are currently applied for Prescription Drug Plan (PDP) sponsors and Medicare Advantage organizations. These responsibilities are not meant to detract from or weaken any current State or CMS oversight responsibilities, including oversight by the Medicare Drug Benefit Group and other relevant CMS groups and divisions, as those responsibilities continue to apply, but rather to assure that such responsibilities are undertaken in a coordinated manner. Neither party shall take a unilateral enforcement action relating to day-to-day oversight without notifying the other party in advance.