Common use of Oversight Framework Clause in Contracts

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. 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 Commonwealth State will require Participating Plans the FIDA-IDD Plan to have a comprehensive plan to detect, correct, prevent, and report fraud, waste, and abuse. Participating Plans The FIDA-IDD Plan must have policies and procedures in place to identify and address fraud, waste, and abuse at both the Plan plan and the third-party levels in the delivery of Plan FIDA-IDD Demonstration benefits, including prescription drugs, medical care, developmental, habilitation, behavioral health, and long term services Community- based and supportsFacility-based LTSS. In addition, all Medicare Part D requirements and many Medicare Advantage requirements regarding oversight, monitoring, and program integrity will be applied to Demonstration Plans the FIDA-IDD Plan by CMS in the same way they are currently applied for PDP 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. ● The Contract Management Team.

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 State 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 as specified in the three-way contract 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. CMS and the State will align oversight, monitoring, and reporting in the Demonstration with regulatory oversight of nursing homes to the extent practicable. 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, except in emergency or urgent situations as described in (e) below.