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Provider Manual

Medicare Advantage Reporting Requirements

Last Updated on January 24, 2019

Required information – Security Health Plan shall have an effective procedure to develop, compile, evaluate, and report to CMS, to its enrollees, and to the general public, at the times and in the manner that CMS requires. At the same time, Security Health Plan safeguard the confidentiality of the doctorpatient relationship, statistics and other information with respect to the following:

  • Cost of operations
  • Patterns of utilization of services
  • Availability, accessibility, and acceptability of services
  • To the extent practical, developments in the health status of its enrollees
  • Information demonstrating that Security Health Plan has a fiscally sound operation
  • Other matters that CMS may require

Fiscal soundness - Security Health Plan shall submit to CMS electronically through the Health Plan Management System (HPMS) an independently audited financial statement, using Statutory Accounting Principles (SAP). In addition, Security Health Plan shall enter 13 financial data elements from the corresponding statements into HPMS. These independently audited financial statements must be submitted to CMS no later than April 30 of the following year.

Significant business transactions – Security Health Plan shall report to CMS annually within 120 days of the end of its fiscal year (unless for good cause shown, CMS authorizes an extension), the following:

  • A description of significant business transactions (as defined in §422.500) between Security Health Plan and a party in interest
  • With respect to business transactions, Medicare Advantage organizations must provide either a showing that the costs of the transactions listed do not exceed the costs that would be incurred if these transactions were with someone who is not a party in interest, or if they do exceed a limit of $25,000 or 5 percent of the Medicare Advantage organization’s total operating expenses, a justification that the higher costs are consistent with prudent management and fiscal soundness requirements
  • A combined financial statement for Security Health Plan and a party in interest if either of the following conditions are met: 35 percent or more of the costs of operation of Security Health Plan go to a party in interest; or 35 percent or more of the revenue of a party in interest is from Security Health Plan

Requirements for combined financial statements:

  • The required combined financial statements must display in separate columns the financial information for Security Health Plan and each of the interested parties.
  • Inter-entity transactions must be eliminated in the consolidated column.
  • Statements must have been examined by an independent auditor in accordance with generally accepted accounting principles and must include appropriate opinions and notes.

Upon written request from Security Health Plan showing good cause, CMS may waive the requirement that the organization’s combined financial statement include the financial information required in this paragraph with respect to a particular entity.

Reporting and disclosure under ERISA:

  • For any employees’ health benefits plan that includes a Medicare Advantage organization in its offerings, Security Health Plan shall furnish, upon request, the information the plan needs to fulfill its reporting and disclosure obligations (with respect to Security Health Plan) under the Employee Retirement Income Security Act of 1974 (ERISA).
  • Security Health Plan shall furnish the information to the employer or the employer’s designee, or to the plan administrator, as the term “administrator” is defined in ERISA.

Loan information – Security Health Plan shall notify CMS of any loans or other special financial arrangements it makes with contractors, subcontractors, and related entities.

Enrollee’s access to information – Security Health Plan shall make the information reported to CMS under §422.504(f)(1) available to its enrollees upon reasonable request.