Carepoint Medicare Compliance Training Program for FDRA

• 1. MEDICARE COMPLIANCE TRAINING PROGRAM FOR FDRs www.carepoint.org

2. Instructions CMS (the Center for Medicare and Medicaid Services, is a Federal agency that provides oversight of Medicare, Medicaid and Children's Health Insurance Program) requires Medicare Advantage Prescription Drug Plans (MA-PDs) to incorporate effective compliance training and education for all first tier, downstream and related entities (FDRs) into their Compliance Programs. The first half of these slides provide information regarding CarePoint Health Plans Medicare Compliance Program Requirements for FDRs pursuant to your contract with CarePoint Health Plans. These requirements are consistent with the CMS Compliance Program Guidelines (Chapter 9 of the PDB Manual/Chapter 21 of the MMC Manual). The second half of this FDR compliance training includes information on CarePoint Health Plans Medicare Compliance Program. FDRs may use these slides for their annual compliance training. Using these slides is not required. FDRs may also elect to develop their own compliance training materials or use materials provided by another Medicare Advantage Organization or Part D Plan Sponsor, consistent with your contract with CarePoint Health Plans. 3. Instructions At the time of contracting and at least annually, you will be required to attest to your compliance with the CarePoint Health Plans Medicare Compliance Program Requirements for FDRs. You will need to complete the Annual Medicare Compliance Program Attestation and return the signed original to CarePoint Health Plans. CarePoint Health Plans reserves the right to perform an audit of your compliance program. FDRs may be asked to provide policies and procedures regarding their compliance program, compliance training materials used for compliance training , attendance logs that demonstrate all employees have received the training, and any other documentation demonstrating the effectiveness of the compliance program. 4. Welcome to FDR Compliance Training This training is comprised of two sections: 1) A review of CarePoint Health Plans Medicare Compliance Program Requirements for FDRs Consistent with CMS' Compliance Program Guidelines (Chapter 9 of the PDB Manual/Chapter 21 of the MMC Manual). As outlined in your agreement with CarePoint Health Plans and described in your Annual Medicare Compliance Attestation 2) An overview of CarePoint Health Plans Medicare Compliance Program, including: Overview of CarePoint Health Plans Principles of Professional Conduct How to report compliance violations and who to contact with Medicare compliance questions CarePoint Health Plans Non-Retaliation Policy Possible disciplinary/corrective actions for non-compliance or fraud 5. What is the definition of an FDR Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan CarePoint Health Plans 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. First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with an MAO or Part D plan CarePoint Health Plans or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. Related entity means any entity that is related to an MAO or Part D CarePoint Health Plans by common ownership or control and 1. Performs some of the MAO or Part D plan CarePoint Health Plans 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 CarePoint Health Plans at a cost of more than $2,500 during a contract period. 6. Examples of FDRs Management service organizations (MSOs), Provider groups, hospitals, skilled nursing facilities, Pharmacy benefit managers (PBMs), Marketing firms, field marketing organizations, Claims processing and adjustment companies, Temporary employment agencies, and others. The following is not considered an FDR: A real estate broker whose business relationship with CarePoint Health Plans is limited to the office space rentals 7. Why is compliance training for FDRs important? CarePoint Health Plans has entered into a contracts with its FDRs to perform certain functions that would otherwise be the responsibility of CarePoint Health Plans. While CarePoint Health Plans may contract with FDRs to perform certain functions on its behalf, CarePoint Health Plans maintains ultimate responsibility for fulfilling the terms and conditions of its contract(s) with CMS and for meeting the Medicare program requirements, including the Compliance Program requirements. CMS has the authority to hold CarePoint Health Plans accountable for any failure to meet the program requirements, even if the failure is due to its FDRs' conduct. Both CarePoint Health Plans and its FDRs may be subject to liability under civil and/or criminal laws, such as the False Claims Act or the Anti-Kickback statute for fraud perpetrated in the administration or delivery of Parts C and D benefits. 8. General CarePoint Medicare Compliance Requirements for FDRs All FDRs to whom CarePoint Health Plans has delegated responsibilities related to its core functions under its Medicare contracts with CMS are required to be in compliance with all applicable laws, rules and regulations with respect to Parts C and D delegated responsibilities. Consistent with the above requirement, FDRs should report all suspected, potential or actual instances of Medicare program non-compliance and FWA to CarePoint Health Plans. All Compliance Program Requirements apply to the FDR and the FDR's employees, unless otherwise indicated. FDR Employees are defined as any person under control of the FDR (intern, volunteer, consultant, temporary or permanent, full or part-time, regardless of payment) who has contact with a Medicare beneficiary, orally or in writing, or a Medicare beneficiary's information (such as claims, letters or medical records) 9. Requirements for Exclusion Lists Reviews All FDRs must ensure monthly screening of HHS OIG List of Excluded Individuals and Entities (LEIE list) exclusion and GSA debarment lists prior to the hiring or contracting of any prospective, potential or actual new employee, temporary employee, volunteer, consultant, governing body member, or downstream and related entities, and monthly thereafter, to ensure that none of these entities are excluded or become excluded from participation in federal programs , as required by 42 CFR 422.503(b)(4)(vi)(F), 423.504(b)(4)(vi)(F), 42 CFR 1001.1901 If an FDR should discover an excluded individual, the FDR should immediately disclose this information to CarePoint Health Plans. All FDRs must ensure there are procedures to identify and prevent payment for any item or service provided by an excluded person or entity FDRs and their employees must immediately disclose any exclusion or other event that make them ineligible to perform work related to Federal Health Care Programs. 10. Requirements for Reporting Conflicts of Interest All FDRs are required to effectively screen both their senior management and governing body for conflicts of interest with CarePoint Health Plans interests and disclosure to CarePoint Health Plans upon identification of any Conflicts of Interest, at the time of contracting and annually thereafter, as required by 42 CFR 422.503(b)(4)(vi)(A)(3), 423.504(b)(4)(vi)(A)(3). An effective conflicts of interest screening process may including the following: At time of hire/appointment and annually Ensuring the person has reviewed the organization's* conflict of interest policy n Determining whether the person has disclosed any conflicts of interest, and whether management has allowed the person to work despite the conflicts of interest, or whether the conflicts of interest have been eliminated *If the organization does not have its own conflicts of interest policy, the organization may adopt CarePoint Health Plans conflicts of interest policy, which is easily available in CarePoint Health Plans Standard of Conduct 11. Requirements for Compliance Policies All FDRs are required to have and distribute compliance policies (including a conflicts of interest policy and non- intimidation, non-retaliation policy) and standards of conduct annually and within 90 days of hire, and whenever compliance policies and standards of conduct are updated/revised. All FDRs are required to have their employees sign that they have read and agree to comply with written policies and standards of conduct, within 90 days of hire and annually thereafter. The FDR may use CarePoint Health Plans compliance materials or compliance materials that are comparable 12. Requirements for Compliance Policies CarePoint Health Plans need not review and approve the FDR's compliance materials in advance to ensure consistency with CMS requirements; however, CarePoint Health Plans will be held accountable for ensuring that their FDRs have compliance materials that meet CMS requirements. All FDRs should inform their employees that violation of standards will result in appropriate disciplinary action, up to and including termination of employment. All FDRs must encourage their employees' to ask compliance questions and report potential instances of Medicare program noncompliance and FWA confidentially or anonymously (if desired) without fear of retaliation. 13. Requirements for Compliance Training The FDR's Compliance Program must be communicated using training and educational materials, as required by 42 CFR 422.503(b)(4)(vi)(C),423.504(b)(4)(vi)(C) At a minimum, FDRs must conduct compliance training, at the following times: Within 90 days of hire, for all new employees At the time of appointment for a new Chief Executive, manager or governing body member Annually 14. Requirements for Compliance Training CarePoint Health Plans requires that FDRs administer specialized compliance training FDR employees upon hire and annually thereafter. This training should be based on issues posing a compliance risk based on an individual's job function, when an FDR employee is found to be non-compliant and/or working in an area found to be non-compliant or implicated in past misconduct. 15. Requirements for Maintaining Records The FDR should maintain records that demonstrate its compliance with these Medicare Compliance Program Requirements for FDRs Records should be maintained for no less than ten (10) years Records may include compliance program materials, training attendance logs and test results, FDR employee attestations for completion of training 16. Requirements for Corrective Action Plans For corrective actions related to misconduct or program noncompliance by an FDR, all elements of the corrective action are detailed in a written agreement with the FDR. The written agreement will include ramifications if the FDR fails to implement the corrective action satisfactorily. 17. How to Report Compliance & FWA Issues within your Organization FDRs of CarePoint Health Plans should have policies and procedures that address Medicare program non- compliance and fraud, waste and abuse. These policies and procedures should address the following: What situations may be considered red flags for fraud? What methods will be used to prevent and detect fraud, waste and abuse activities? How and who will investigate situations that are reported? How will employees report this information? How will employees be protected from retaliation should they report a potential issue? What corrective and/or disciplinary actions will be taken if fraud, waste or abuse occurs? How will employees receive education on these policies and procedures? FDRs of CarePoint Health Plans MUST report any potential fraud, waste or abuse related to CarePoint Health Plans Part C and D lines of business to CarePoint Health Plans (or if preferred, to an external agency). Instructions for reporting to CarePoint Health Plans are included later within this training. 18. FDRs Non-Intimidation, Non-Retaliation FDRs are required to have a non-intimidation, non-retaliation policy, and to the extent that an FDR does not have one, the FDR may choose to adopt CarePoint Health Plans policy, which is easily available in CarePoint Health Plans Standards of Conduct. Below are recommended elements for inclusion in a Non-Intimidation, Non- Retaliation policy: Employees should be encouraged to report any potential fraud, waste or abuse that they know or think they know is occurring. Employees that do make a report must not be retaliated against for making the report. This is true for good-faith reports. Employees that are found to have made a report because they are disgruntled or have other inappropriate motivation may not be afforded the same protections. Employees should be given a means to make a report anonymously if they choose. This can be accomplished by using an anonymous hotline or a third party reporting vendor. Employees that retaliate against another employee that has made a good-faith report should be subject to corrective action up to and including termination. 19. FWA training requirements for FDRs CMS has developed a standardized web-based Medicare Part C and D FWA training and education module. The module is available through the CMS Medicare Learning Network (MLN) at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/WebBasedTraining.html Under "Related Links", at the bottom of the page, click on "Web-Based Training (WBT) Courses". Click on Medicare Parts C and D Fraud, Waste and Abuse Training The CMS standardized FWA training should be used by any FDR who is NOT deemed and for whom CarePoint Health Plans has not separately provided its own FWA training materials. 20. FWA training requirements for FDRs FDRs who have met the FWA certification requirements through enrollment into the Medicare program or accreditation as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) are deemed to have met the training and educational requirements for fraud, waste, and abuse. No additional documentation beyond the documentation necessary for proper credentialing is required to establish that an FDR or employee of an FDR is deemed. However, even if "deemed" for FWA training, FDR's employees still must have compliance training. 21. Compliance is Your Responsibility All employees are held accountable for compliance, from the top to the bottom of the organization Compliance is a part of your day-to-day responsibilities Managers must ensure that employees are fully trained in all standards, policies and procedures Employees should request additional training to ensure they are performing/behaving in compliant manner 22. Written Policies and Procedures CMS requires CarePoint Health Plans to have written Standards of Conduct. The Standards of Conduct and compliance policies reflect CarePoint Health Plans commitment to integrity, ethical conduct and legal/regulatory compliance. The Standards of Conduct communicates to our FDRs Compliance is everyone's responsibility from the top to the bottom of the organization. How to deal with potential compliance issues. The responsibility to report violations of law, regulations, Medicare program requirements fraud, waste and abuse (FWA) and any Medicare Compliance Program Requirements to CarePoint Health Plans. 23. Written Policies and Procedures All entities contracted to perform work related to Medicare programs must review CarePoint Health Plans Standards of Conduct and policies and procedures or have appropriate policies and procedures to address ethical conduct, as well as a compliance program to address Medicare program non- compliance and Fraud, Waste and Abuse. 24. What is Wrongdoing Wrongdoing: Examples of wrongdoing, which may lead to disciplinary and or corrective action, include but not limited to: Illegal or fraudulent activity Violations of law, regulations or CMS Medicare program requirements Failing to disclose Conflicts of interest or failing report acts of wrong-doing, including non- compliant, dishonest or unethical conduct Violations of the Standards of Conduct and/ or company policies Encouraging or assisting others in acts of non-compliance 25. What is Wrongdoing Failure to meet compliance program training requirements, or other such requirements of CarePoint Health Plans Medicare Compliance Program Knowingly submitting false reports of non-compliance Retaliation against an employee or contractor for their good faith participation in the Medicare Compliance Program and/or reporting FWA, non-compliance, or other acts of wrongdoing This list above is provided as a guide to assist Associates in identifying specific conduct that may constitute grounds for disciplinary and/or corrective action, including termination of employment, affiliation, appointment or contract; however, it is not exhaustive. 26. Requirement to Report Wrongdoing ALL FDRs (and their employees) are required to report Wrongdoing, especially suspected Fraud FDR's board members, managers and employees may report Wrongdoing related to CarePoint Health Plans to the CarePoint Health Plans or to any external federal or state law enforcement agency (for suspected cases of fraud) 27. How to Report Wrongdoing to CarePoint Health Plans All wrongdoing, including ethical issues, potential conflicts of interest, potential compliance issues, fraud allegations, etc, may be reported to CarePoint Health Plans using any of the following means: By calling or emailing CarePoint Health Plans Compliance Officer Ajhezza Gonzalez (201) 432.2133 X103 [email protected] By mail: Ajhezza Gonzalez, Compliance Officer, CarePoint Health Plans Harborside Financial Center-Plaza Five-Suite 1510 Jersey City, NJ 07311 Compliance Hotline: 1-888-671-6191 (Completely anonymous unless you choose to give your name) Compliance Fax: 908-378-7846 Compliance Email: [email protected] 28. How to Report Suspected Fraud to External Agency New Jersey Office of the Attorney General: 1-609-292-4925 New Jersey Department of Banking and Insurance, Frauds Bureau: 1-800-446-7467 Call 1-800-MEDICARE or Call 1-800-HHS-TIPS 29. Responding to Compliance Issues When you report a compliance issue to CarePoint Health Plans, you may be asked a series of questions to assist in the investigation. Please give as much detail as possible about the issue. The Compliance Officer, or designee, thoroughly investigates each report of an alleged violation of the Medicare Compliance Program Applicable federal and state laws and regulations and Medicare program requirements CarePoint Health Plans standards of conduct, policies and procedures Reports of Wrongdoing 30. Responding to Compliance Issues Confirmed cases of violations will be handled as follows Corrective actions will be implemented ASAP Self-reporting to government agencies, involvement of legal counsel, if necessary To prevent future violations, there will be immediate training and potentially a review of policies and procedures to determine any needed revisions Follow-up auditing and monitoring 31. Corrective Actions Compliance violations and acts of Wrongdoing are subject to corrective actions The CarePoint Health Plans Compliance Officer may request a correction action plan (CAP) and/or recommend specific corrective actions be implemented to remediate the compliance violation or deficiency. Depending on the severity of the issue, the FDR may be sanctioned and the contract may be terminated. For staff who are involved in the wrongdoing, the CarePoint Health Plans Compliance Officer may request the corrective actions include disciplinary action up to and including termination of the individual(s). 32. CMS may impose Sanctions against CarePoint for Non-Compliance Notices of non-compliance Warning Letters Requests for Corrective Action Plans Suspension of Enrollment and Marketing Fines Sanctions vary with the severity, repetition of the deficiency and impact to members. 33. Auditing & Monitoring CarePoint Health Plans, or an organization on its behalf, may conduct Annual Risk Assessments and Audits of its FDRs to ensure FDRs are meeting requirements of the FDR's contract Internal Audits Although FDRs may conduct their own internal audits and provide their annual audit plan and the results of their audits to CarePoint Health Plans, CarePoint Health Plans reserves the right to conduct its own audits (as required by CMS). CMS or other regulatory or enforcement agencies may conduct their own audits All FDRs and their employees are expected to fully cooperate with all auditing and monitoring activities. 34. CarePoints Non-Intimidation, Non-Retaliation Policy CarePoint Health Plans will not discriminate or retaliate against anyone or any FDR who, in good faith, reports Wrongdoing, including violations of laws or regulations, the Standards of Conduct, or CarePoint Health Plans policies. Retaliation should be reported to the Medicare Compliance Officer