Common use of Oversight Framework Clause in Contracts

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. 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. 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.coordination.‌