Affinity Health Plan

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    Affinity requires our providers to conduct business directly or indirectly related to Affinity in a compliant, ethical, and legal manner.  In accordance with Centers for Medicare & Medicaid Services (CMS) requirements, Medicare Advantage Organizations (MAO), Medicare-Medicaid Plans (MMP) and Medicare Part D (PDP) sponsors are obligated to require completion of annual fraud, waste, and abuse (FWA) and general compliance training by their first-tier, related, and down-stream entities (FDR).  In addition, FDRs are required to monitor federal exclusions lists on a monthly basis as well as annually distribute code or standards of conduct information.

    Affinity uses the Centers for Medicare & Medicaid Services (CMS) standardized Medicare Parts C & D Fraud, Waste and Abuse (FWA) and General Compliance training module.  This training module satisfies the regulatory requirement for effective training and education (42 CFR 422.503 and 42 CFR 423.504) and is referenced below along with other compliance-related documents for your convenience.

    In order to comply with CMS requirements, Affinity asks that each of our contracted network providers review the CMS training materials along with Affinity's Code of Ethics (the standards of conduct for Affinity employees, board members, providers, vendors, and business partners) and attest that, to the extent required, will operate in a manner consistent with this document and training materials.

    This attestation is required to be completed by December 31 of each calendar year.  Each contracted network provider must complete Affinity's compliance attestation indicating that they have received and completed FWA and general compliance training materials and are applying the additional compliance requirements concerning Medicare Advantage, Medicare-Medicaid Plans (MMP) and Medicare Part D business. 

    Note that completion of the Affinity attestation is still required if your organization qualifies for the waiver based on meeting the fraud, waste, and abuse certification requirements through enrollment into the Medicare program or accreditation as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider and are deemed to have met the training and education requirements for fraud, waste, and abuse per 42 CFR 423.504.  To indicate the deemed status, please check the appropriate section of the attestation.

    Provider Compliance Requirements
    • Actively monitor the activities of employees (paid or unpaid, regardless of position including volunteers and interns) and contractors performing Affinity-related business.
    • Adopt and distribute a code of conduct as well as compliance policies and procedures to employees (paid or unpaid, including volunteers and interns) and contractors within 90 days of hire or contract and annually thereafter.
    • Distribute annual compliance and fraud, waste, and abuse (FWA) training to employees (paid or unpaid, including volunteers and interns) and contractors within 90 days of hire or contract and annually thereafter. The approved general compliance and FWA training is available through the CMS Medicare Learning Network website at www.cms.gov.
    • Conduct exclusion screening prior to hire or contract, and monthly thereafter, to confirm employees and contractors are not excluded to participate in Federally-funded health care programs according to the OIG-HHS and SAM exclusion lists.
    • Disclose current/changes to ownership and controlling interest, including any debarment or suspension status and any criminal convictions related to Federal health care programs of managing employees and anyone with an ownership or controlling interest in the organization or a related entity. All requests for disclosure of ownership, controlling interest, business transactions, or related information made by Affinity or a governmental agency must be fulfilled within 35 days of the date of a request.
    • Report actual or potential fraud, waste, and abuse (FWA) and compliance concerns, suspected violations of applicable fraud laws and regulations, including the False Claims Act, as it relates to Affinity.
    • Maintain information relating to Affinity's business, including evidence of training, for a period of ten (10) years and provide information upon request by Affinity, an Affinity representative, or an authorized party (e.g., the government) for monitoring and auditing purposes. 
    • Cooperate with audits or investigations being conducted by Affinity, a party designated by Affinity, and a law enforcement, regulatory, or oversight agency.
    Summary of Provider Compliance Steps
    • Complete the training and review Affinity's Code of Ethics.
    • Keep a copy of information relating to Affinity's business, including training materials and other compliance-related documentation for audit purposes. 
    • On an annual basis, complete and submit the Attestation form to Affinity as outlined on the form.
    • Continue to operate in a compliant matter.

    Provider Compliance Resources
    Training: Medicare Parts C & D Fraud, Waste, and Abuse (FWA) and General Compliance training module

    Standards of Conduct: Affinity Code of Ethics

    Sanction Screening Resources:

    Provider Attestation Form: Affinity's Provider Compliance Attestation

    Special Needs Plan Model of Care: Information about Affinity’s Model of Care (MOC).

    Disclosure of Ownership:

    Definitions of First Tier, Downstream, and Related Entity
    Affinity's business partners considered an FDR include hospitals, providers, ancillaries, and a portion of our vendors. Below is a list of administrative or health care services examples that qualify a vendor as an FDR:

    • Sales and marketing
    • Utilization management
    • Quality improvement
    • Applications processing
    • Enrollment, disenrollment, membership functions
    • Claims administration, processing and coverage adjudication
    • Appeals and grievances
    • Licensing and credentialing
    • Pharmacy benefit management
    • Hotline operations
    • Customer service
    • Bid preparation
    • Outbound enrollment verification
    • Provider network management
    • Processing of pharmacy claims at the point of sale
    • Negotiation with prescription drug manufacturers and others for rebates, discounts or other price concessions on prescription drugs
    • Administration and tracking of enrollees' drug benefits, including true out-of-pocket (TrOOP) balance processing
    • Coordination with other benefit programs such as Medicaid, state pharmaceutical assistance or other insurance programs
    • Entities that generate claims data
    • Health care services

    First Tier Entity
    Defined as any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organizations (MAO) or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the Medicare Advantage program or Part D program.

    Downstream Entity
    Defined as any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage (MA) benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.

    Related Entity
    Defined as any entity that is related to an MAO or Part D sponsor by common ownership or control and (1) Performs some of the MAO or Part D plan sponsor's management functions under contract or delegation; (2) Furnishes services to Medicare enrollees under an oral or written agreement; or (3) Leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period.