Introduction to Kaiser Permanente Medicare Advantage plans

Kaiser Permanente contracts with the Centers for Medicare & Medicaid Services (CMS) to offer Medicare Advantage plans, to eligible members. See Kaiser Permanente Medicare Plans for a list of service areas for each of Medicare Advantage plans.

Note: CMS guidelines have significant implications for Kaiser Permanente and our contracted providers. As you carefully review the information that follows, please note and discuss with applicable business partners those mandates requiring action on your part (or theirs) to achieve compliance.

You should be familiar with both CMS fee-for-service and Medicare Advantage regulations. For Kaiser Permanente and all of our contracted providers, these regulations mean:

• Health plans and providers must take proactive measures to implement federal requirements. Failure to do so may result in significant penalties for you and Kaiser Permanente.
• Numerous requirements extend beyond the usual health plan/provider contracting relationship. Selected CMS directives to Medicare Advantage plans also apply to contracts for services to which Kaiser Permanente is not a party. In order to meet CMS requirements, if you have signed a contract with another entity to provide health care services to our members, that contract must include language that is substantially similar to language in your contract with Kaiser Permanente.
• You share accountability with Kaiser Permanente for meeting federal requirements. Please carefully assess the adequacy of any subcontracts you have with other practitioners, shadow networks, or downstream entities in caring for Medicare Advantage members, and initiate necessary contract modifications as soon as possible.
• Individuals who work directly or indirectly on any Federal health care program may not appear in the List of Excluded Individuals/Entities as published by the Department of Health and Human Services Office of the Inspector General, or in the List of Debarred Contractors as published on the Excluded Parties List System by the General Services Administration. Providers are expected to:
  • Verify that any new employees, contractors, board members, or shareholders are not on these lists prior to hire.
  • Review these lists on a monthly basis for any of their employees, contractors, board members, or shareholders.
  • Take appropriate corrective action and contact us, if any of these individuals is on such lists.
  • Keep a record that such reviews have been completed for compliance.

Communications to Medicare Advantage members

As a Medicare Advantage Organization (MAO), Kaiser Permanente is also required to adhere to numerous CMS guidelines regarding communication with Medicare Advantage members and is ultimately accountable for all communications from providers to its Medicare Advantage members. To ensure compliance with CMS requirements, all proposed provider communications to Medicare Advantage members regarding Medicare Advantage plans must be submitted to Kaiser Permanente for review and approval prior to mailing.

In order for Kaiser Permanente to have adequate time to review and respond to your request, please submit draft provider communications at least 60 days* in advance of the mailing date to either of the following addresses:

Kaiser Foundation Health Plan of Washington
Provider Relations Compliance
P.O. BOX 34262
Seattle, WA 98124-1262

prcompliance@ghc.org

Provider Relations Compliance will notify you in writing once your request has been received and once a final determination has been made.

*In some instances, it can take CMS up to 45 days to review and render a decision.