Summary of requirements for Kaiser Permanente Medicare Advantage plans

Providers must:

1. Document services and maintain records in the form and manner required by law, acceptable medical practice and professional ethics.
2. Safeguard the privacy of any information that identifies a particular member and maintain the records in an accurate and timely manner.
3. Maintain and protect the confidentiality of patient records as provided by state and federal law.
4. Submit to Kaiser Permanente Medicare Advantage all data, including medical records, necessary to characterize content/purpose of each encounter with all Kaiser Permanente Medicare Advantage members.
5. Certify the completeness and truthfulness of encounter data, and submit accurate, complete, and truthful data to Kaiser Permanente Medicare Advantage.

Note: Kaiser Permanente Medicare Advantage must develop, compile, evaluate, and report to CMS and other entities information including, but not limited to:

• Cost of its operations
• Utilization patterns
• Availability, accessibility and acceptability of services
• Health status of members
• Proof of fiscal soundness

Upon request, Kaiser Permanente Medicare Advantage must submit applicable information to ensure compliance with this requirement.

Discrimination against beneficiaries prohibited. (a) General prohibition. Except as provided in paragraph (b) of this section, an MA organization may not deny, limit, or condition the coverage or furnishing of benefits to individuals eligible to enroll in an MA plan offered by the organization on the basis of any factor that is related to health status, including, but not limited to the following:

(1) Medical condition, including mental as well as physical illness.

(2) Claims experience.

(3) Receipt of health care.

(5) Genetic information.

(6) Evidence of insurability, including conditions arising out of acts of domestic violence.

(7) Disability.

(b) ESRD. As of 2021, an MA organization may enroll an individual who has been medically determined to have end-stage renal disease.

(a) Rules for coordinated care plans. An MA organization that offers an MA coordinated care plan may specify the networks of providers from whom enrollees may obtain services if the MA organization ensures that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan. To accomplish this, the MA organization must meet the following requirements:

(8) Cultural considerations. Ensure that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds.

Kaiser Permanente Medicare Advantage must pay for emergency and urgently needed care consistent with provisions of 422.113(b), which defines emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

1. Serious jeopardy to the health of the individual, or in the case of a pregnant woman, the health of the unborn child.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.

Advance directives are documents that competent adults can create. An adult person is defined as a person who has attained the age of majority as defined by RCW 26.28.010 and RCW 26.28.015 and who has the capacity to make health-care decisions. (See Chapter RCW 70.122.)

Primary care providers must document in the member's medical record whether the member has completed an advance directive.

Hospitals, skilled nursing facilities, and inpatient psychiatric facilities must provide for member or representative involvement in decisions to withhold resuscitative services or to forgo or withdraw life-sustaining treatment.

Providers must cooperate fully with:

• An independent quality review and improvement organization's activities pertaining to provision of services for Medicare members in a Kaiser Permanente Medicare Advantage plan.
• Kaiser Permanente Medicare Advantage medical policy, quality assurance and medical management programs. Kaiser Permanente Medicare Advantage must develop such standards in consultation with contracting providers.

Kaiser Permanente Medicare Advantage must disclose to CMS quality and performance indicators for the benefits under the plan regarding disenrollment rates for Medicare members enrolled in the plan for the previous two years.

Kaiser Permanente Medicare Advantage must disclose to CMS quality and performance indicators for the benefits under the plan regarding member satisfaction.

Kaiser Permanente Medicare Advantage must disclose to CMS quality and performance indicators for the benefits under the plan regarding health outcomes.

Kaiser Permanente Medicare Advantage must notify providers in writing of reasons for suspension and termination determinations that affect physicians.

Note: This requirement applies to physicians only. CMS defines physicians as MDs, DOs, DCs, DPMs, and ODs.

All written arrangements between Kaiser Permanente Medicare Advantage and its providers (and between providers and downstream contracting entities) must contain language specifying that the first tier and downstream entities comply with applicable Medicare laws and regulations, and Kaiser Permanente Medicare Advantage and providers must meet requirements of all other laws and regulations including:

• Title VI and Title VII of the Civil Rights Act of 1964
• The Equal Employment Opportunity Act of 1972
• The Rehabilitation Act of 1973
• The Vietnam Era Veteran's Readjustment Act of 1974
• The Age Discrimination Act of 1975
• The Americans with Disabilities Act of 1990
• All other laws applicable to federal funding recipients