Additional Medicare Advantage Requirements
As an Medicare Advantage (MA) organization, UnitedHealthcare and its network care providers agree to meet all laws and regulations applicable to recipients of federal funds.
If you participate in the network for our MA products, you must comply with the following additional requirements for services you provide to our MA members.
- You may not discriminate against members in any way based on health status.
- You must allow members direct access to screening mammography and influenza vaccination services.
- You may not impose cost-sharing on members for the influenza vaccine or pneumococcal vaccine or certain other preventive services. For additional information, please refer to the Medicare Advantage Coverage Summary for Preventive Health Services and Procedures, available on Coverage Summaries for Medicare Advantage Plans page.
- You must provide female members with direct access to a women’s health specialist for routine and preventive health care services.
- You must make sure members have adequate access to covered health services.
- You must make sure your hours of operation are convenient to members.
- You must make sure medically necessary services are available to members 24 hours a day, seven days a week.
- Primary care providers must have backups for absences.
- You must adhere to CMS marketing regulations and guidelines. This includes, but is not limited to, the requirements to remain neutral and objective when assisting with enrollment decisions, which should always result in a plan selection in the Medicare beneficiary’s best interest. CMS marketing guidance also requires that providers must not make phone calls or direct, urge, or attempt to persuade Medicare beneficiaries to enroll or disenroll in a specific plan based on the care provider’s financial or any other interest. You may only make available or distribute benefit plan marketing materials to members in accordance with CMS requirements.
- You must provide services to members in a culturally competent manner taking into account limited English proficiency or reading skills, hearing or vision impairment, and diverse cultural and ethnic backgrounds.
- You must cooperate with our procedures to tell members of health care needs that require follow-up and provide necessary training to members in self-care.
- You must document in a prominent part of the member’s medical record whether they have executed an advance directive.
- You must provide covered health services in a manner consistent with professionally recognized standards of health care.
- You must make sure any payment and incentive arrangements with subcontractors are specified in a written Agreement, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards.
- You must comply with all applicable federal and Medicare laws, regulations, and CMS instructions, including but not limited to: (a) federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including but not limited to applicable provisions of federal criminal law, the False Claims Act (31 U.S.C. §3729 et seq.), and the Anti-Kickback Statute (§1128B of the Social Security Act); and (b) HIPAA administrative simplification rules at 45 CFR Parts 160, 162, and 164.
- The payments you receive from us or on behalf of us are, in whole or in part, from federal funds and you are therefore subject to certain laws applicable to individuals and entities receiving federal funds.
- You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the MA Program and disclose all information determined by CMS to be necessary to assist members in making an informed choice about Medicare coverage.
- You must comply with our processes for notifying members of your Agreement terminations.
- You must submit all risk adjustment data as defined in 42 CFR 422.310(a), and other MA program-related information as we may request, to us within the timeframes specified and in a form that meets MA program requirements. By submitting data to us, you represent to us, and upon our request you shall certify in writing, that the data is accurate, complete, and truthful, based on your best knowledge, information and belief.
- You must comply with our MA medical policies, Policy Guidelines, Coverage Summaries, quality improvement programs, and medical management procedures.
- You must cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance, and other indicators as specified by CMS.
- You must cooperate with our procedures for handling grievances, appeals and expedited appeals. This includes, but is not limited to, providing requested medical records within two hours for expedited appeals and 24 hours for standard appeals, including weekends and holidays.
- In addition, you must comply with the Medicare Advantage Regulatory Requirements Appendix (MARRA).
Member Communication (CMS Approval Required)
Member communications require CMS approval. This includes:
- Anything with the MA and/or the AARP name or logo
- Correspondence that describes benefits
- Marketing activities
Approval is not necessary for communications between care providers and patients that discuss:
- Their medical condition
- Treatment plan and/or options
- Information about managing their medical care
Once CMS approves, we send the letter to the member.
In addition to making sure the letter is approved by the governing regulatory body, we direct the letter to the correct audience. For example, we may need to distinguish a mailing to MA plan individual members versus Medicare group retiree members, as their benefits are distinctly different.
Part C Reporting Requirements
MA organizations are subject to additional reporting requirements. We may request data from our contracted care providers. This data is due by 11:59 p.m. Pacific Time on our established reporting deadline.
Some measures are reported annually, while others are reported quarterly or semi-annually. This includes, but is not limited to:
- Organization Determinations/Reconsiderations including source data for all determinations and reopenings
- Special Needs Plans Care Management
- Mid-Year Network Changes
- Payments to Providers