Summary of requirements for Kaiser Permanente Medicare Advantage plans

This grid includes an overview of key regulations that most impact our contracted providers. The information is not verbatim regulatory language, so providers seeking more detail should refer to the Medicare Managed Care Manual.

If you have questions about the regulations or how they apply to your relationship with Kaiser Permanente Medicare Advantage, please contact your Provider Relations Compliance at prcompliance@kp.org or
Kaiser Foundation Health Plan of Washington
Provider Relations Compliance
P.O. BOX 34262
Seattle, WA 98124-1262
206-988-2000

CMS Regulation(s) (Title 42 CFR) or Operational Policy Letter (OPL) Citation: Summary of Language in the Federal Register
Records retention and inspection
422.504(e)(2)
422.504(e)(3)
422.504(e)(4)
422.504(i)(2)(ii)
Health and Human Services (HHS) and General Accounting Offices (GAO) designees may audit, evaluate, and inspect books, contracts, medical records, patient care documentation, and other records for a period of ten years, or for periods exceeding ten years or completion of an audit, whichever is later, for reasons specified in regulation 422.504(e)(4).
Medical records documentation, privacy/confidentiality, and encounter data requirements
422.118
422.504(a)(13)
422.504(a)(8)
422.504(l)(2)
422.504(l)(3)

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 prohibition
422.110(a)
422.112(a)(8)
Contracting parties may not discriminate in the delivery of care based on Vietnam-era veteran or disabled veteran status and other groups protected by law, genetic information, and source of payment.
Emergency and urgent care payment
422.100(b)

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.
Dialysis services
422.100(b)(1)(iv) Kaiser Permanente Medicare Advantage must pay for renal dialysis services for members temporarily outside the service area.
Access to mammography screening and influenza vaccinations
422.100(g)(1) Medicare members may self-refer for services that they may self-refer for by law (for example, mammography screening and flu shots). Health plan and provider subcontracts may not contain prohibitive language.
Cost-sharing restriction
422.100(g)(2) Kaiser Permanente Medicare Advantage may not impose cost sharing for influenza vaccine and pneumococcal vaccines.
Termination notification
422.111(e) Kaiser Permanente Medicare Advantage must make good faith effort to notify all affected members of the termination of a provider contract within 30 days of notice of termination (either by the health plan or the provider).
Access standards
422.112(a)(1)(i) Kaiser Permanente Medicare Advantage must maintain written agreements with providers to demonstrate adequate access. Network must be sufficient to provide access to covered services.
Women's health care services
422.112(a)(3) Women must have direct access to in-network women's health specialists for routine and preventive services.
Treatment plans for complex or serious medical conditions
442.112(a)(9)(b)(4)(i) Consistent with Kaiser Permanente Medicare Advantage care management practices, Kaiser Permanente Medicare Advantage must have approved procedures in place for — and providers must assist with — identifying, assessing, and establishing treatment plans for persons with complex or serious medical conditions. Kaiser Permanente will make its best efforts to assess such persons within 90 days of enrollment.
Timeliness of treatment
442.112(a)(1)(i)
422.112(a)(6)(i)
422.112(a)(7)
Services provided to members must be of the same quality and provided in the same manner as rendered to other persons by the provider and, at a minimum, shall comply with community standards of accessibility of such services. Services shall be provided without regard to the member's enrollment in a privately or publicly financed program of health care services.
Cultural consideration
442.112(a)(8) Services must be rendered in a culturally considerate manner to all members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities.
Advance directives
422.128(b)(1)(ii)(E)

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.

Health assessment requirements
422.112(b)(4)(i) Kaiser Permanente Medicare Advantage must conduct a health assessment of all new members within 90 days of the effective date of enrollment.
Follow-up and training requirement
422.112(b)(5) Kaiser Permanente Medicare Advantage must maintain procedures to inform members of follow-up care and provide training in self-care as necessary.
Professional standards in providing benefits
422.504(a)(3)(iii) Kaiser Permanente Medicare Advantage must provide all covered services in a manner consistent with professionally recognized standards of health care.
Hold harmless requirement
422.504(g)(1)(i)
422.504(i)(3)(i)
Kaiser Permanente Medicare Advantage must protect members from incurring financial liabilities that are its own legal obligations.
Quality review and medical management
422.202(b)
422.504(a)(5)

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.
Quality reporting requirements
422.504(f)(2)(iv)(A)
422.504(f)(2)(iv)(B)
422.504(f)(2)(iv)(C)

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.

Beneficiary protection
422.504(g)(2)(i)
422.504(g)(2)(ii)
422.504(g)(3)
If Kaiser Permanente Medicare Advantage terminates or does not renew a contract or becomes insolvent, beneficiaries must be protected from benefit loss through discharge date or period for which CMS premium is paid.
Delegation
422.504(i)(3)(iii)
422.504(i)(4)(i)-(v)
Delegation of Kaiser Permanente Medicare Advantage activities or responsibilities must conform with Kaiser Permanente Medicare Advantage delegation requirements in a manner consistent with Medicare Advantage regulation.
Physician payment and incentive
422.208 Payment and incentive arrangements between Kaiser Permanente Medicare Advantage, first tier providers, and downstream entities must be specified in contracts.
Prompt payment provision
422.520(b)(1) Kaiser Permanente Medicare Advantage must insert prompt-payment language in all contracts with providers, with terms agreed to by both Kaiser Permanente Medicare Advantage and the relevant provider.
Suspension and termination requirements
422.202(d)(1)

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.

Pretermination notification
422.202(d)(4) Kaiser Permanente Medicare Advantage and contracting providers must provide at least 60 days' notice before terminating a contract without cause.
Compliance with applicable laws and regulations
422.504(h)(1)
422.504(i)(4)(v)

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
Laws governing entities receiving federal funds
422.504(h) Kaiser Permanente Medicare Advantage contracts, first tier contracts, and downstream entity's contracts are subject to laws applicable to individuals and entities receiving federal funds and must be notified as such.
Excluded providers prohibition
422.752(a)(8) Kaiser Permanente Medicare Advantage and its providers who contract with downstream entities may not employ or contract with individuals excluded from participation in Medicare under section 1128 or section 1128A of the Social Security Act (SSA).
Documenting and tracking member concerns
422.564(g) CMS requires Kaiser Permanente Medicare Advantage and its contracted providers to record complaints made by patients and their significant others. Complaints are to be recorded in a uniform manner that ensures you are responsive to patient concerns.
Expedited appeals requirements
422.562(a) Kaiser Permanente Medicare Advantage and providers must adhere to CMS's appeals/expedited appeals procedures for Kaiser Permanente Medicare Advantage members, including gathering/forwarding information on appeals to Kaiser Permanente Medicare Advantage as necessary.
Meaningful grievance definition requirement
422.561 Kaiser Permanente Medicare Advantage and providers must adhere to CMS's meaningful grievance definition that grievance means any complaint or dispute, other than one that constitutes an organization determination, expressing dissatisfaction with any aspect of a Medicare Advantage organization's or provider's operations, activities, or behavior, regardless of whether remedial action is requested.
Expedited grievance procedures requirements
422.564(f) Kaiser Permanente Medicare Advantage and providers must adhere to CMS's expedited grievance requirements that the Medicare Advantage organization must respond to a member's grievance within 24 hours if the complaint involves a Medicare Advantage organization's decision to invoke an extension relating to an organization determination or reconsideration, and/or the complaint involves a Medicare Advantage organization's refusal to grant a member's request for an expedited organization determination under section 422.570 or reconsideration under section 422.584.
Encounter data
422.504(a)(8)
422.504(i)(2)
422.504(i)(3)
Kaiser Permanente Medicare Advantage must submit encounter data and certify the completeness and truthfulness of the encounter data.

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