CMS Mandated Training

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1 CMS Mandated Training 1. Mandated Training Requirements (who and when) 2. Standards / Code of Conduct 3. HIPAA Privacy and Security 4. Brand New Day Models of Care 5. Quality Improvement Program PRINT Your Name: Print Today s Date: Trainer s Name (if applicable): For Compliance Department Use Only % Correct CAP Required CAP Due CAP Notification Date Scored & Logged by C:\Users\karen\Desktop\02 - CMS Mandated Training doc

2 Brand New Day Medicare Mandated Training Page 2 of 9 Medicare Mandated Training Medicare requires that all health plans and their First Tier, Downstream, and Related entities (FDR s) conduct training with new staff and new contracting entities within 90 (ninety) days of hiring or contracting, and annually thereafter. Training can be conducted by self-study with written materials, webinar, telephonic, or face to face, or by other methods. The areas in which Medicare requires training (and the training materials that may be used) are as follows: Fraud, Waste, and Abuse (CMS materials only) Compliance (CMS materials only) Standards / Code of Conduct (BND or equivalent) Disciplinary Actions (BND or equivalent) HIPAA Privacy and Security (BND or equivalent) Brand New Day Models of Care (BND materials only) Brand New Day QI Program (BND materials only) Brand New Day is committed to complying with all applicable Federal and State standards. Brand New Day posts required training on its website for FDR s to use and if preferred will the training materials upon request. Brand New Day and all FDR s must maintain proof of training for a minimum of 10 (ten) years, and must be able to retrieve and produce the proof upon the request of Brand New Day or Medicare for audit purposes. Annually, FDR s are asked to attest to having completed the training with their staff and downstream contracted entities. The attestation can be faxed to the Compliance Department at , or mailed to Compliance Department, 5455 Garden Grove Blvd., Suite 500, Westminster, CA Test Section A. 1) Brand New Day is committed to complying with all State and Federal Regulations. 2) Medicare requires training by health plans and FDR s of all staff and contracting parties who interact with members or member data within 90 days of hiring / contracting and annually thereafter 3) Training must be done in person at a CMS-certified training facility. 4) Brand New Day requires an attestation annually from its FDR s stating that training was conducted with staff and other contracted entities, and that records will be retained for 10 years at a minimum.

3 Brand New Day Medicare Mandated Training Page 3 of 9 Standards / Code of Conduct Medicare requires that all health plans and their FDR s have standards of conduct (code of conduct) that they share with their contracting and employed staff. The Brand New Day (BND) Code of Conduct (Standards of Conduct) is approved by the Board of Directors annually. FDR s may have their own Code of Conduct or they may adopt and implement the BND Code of Conduct. Staff must sign the Code of Conduct document indicating they have received it and will abide by it. Even the Board of Directors must be trained. The Code of Conduct document should express (at a minimum) the expectation that all staff and contracting entities / parties conduct themselves: in compliance with State and Federal laws and regulations; in an ethical manner; and that suspected fraud, waste, or abuse (FWA) be reported to the health plan via confidential Hotline@universalcare.com; by confidential FAX to ; or by phone to ext 4071 (the Brand New Day Hotline for confidential reporting). The Code of Conduct must include that there will be no retaliation for reporting suspected fraud, waste or abuse (FWA). The Code of Conduct must also include that there are disciplinary guidelines that will be enforced and that failure to correct will result in termination of services. Test Section B. 5) FDR s must have and implement a Code of Conduct. They may use the Brand New Day Standards of Conduct or their own version of a Code of Conduct. 6) No one is obligated to report Fraud, Waste or Abuse (FWA) to BND by phone, fax, , or in person. 7) When BND or an FDR finds out someone reported suspected fraud, the reporting party can expect retaliation. 8) BND and FDR s are required to state that there are Disciplinary Actions for those who do not abide by the Code of Conduct. HIPAA Privacy and Security Guidelines Definitions: HIPAA legislation was passed in 1996 by Congress and includes a privacy rule creating national standards to protect personal health information ( PHI ) and electronic personal health information (ephi). The term Health Information is defined as "any information, whether oral or recorded in any form or medium" that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse"; and Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual." Examples of PHI include a person s name, address, phone number, social security number, Medicare or Medi-Cal number, any diagnoses, treatment, doctor visit information, hospitalization, medical records almost any kind of information about a person must be protected and held in strict confidentiality.

4 Brand New Day Medicare Mandated Training Page 4 of 9 Such information may be communicated by U.S. Mail (inside the envelope), by FAX (with a confidentiality statement on the FAX), or by phone when in a private location where you can t be overheard. Such information may not be sent by unprotected or text message. ( within your own company is okay if protected by a firewall, but you cannot send unprotected outside your company to another health plan, provider, etc.) Faxes and messages should have one of the following statements (or a similar statement) at the bottom of the message: Fax Confidentiality Statement Sample The preceding message may be confidential or protected by law. It is not intended for transmission to, or receipt by, any unauthorized persons. If you have received this message in error, please (a) Do not read it. (b) Do reply to the sender that you received the message in error. (c) Erase or destroy the message. Confidentiality Statement Sample THIS ELECTRONIC TRANSMISSION MAY CONTAIN PROTECTED HEALTH INFORMATION OR OTHER PRIVILEGED INFORMATION. The information contained in this electronic transmission, including any attachments, contains information from Universal Care, Inc. that may include protected health information, or other confidential, proprietary or privileged information as defined by state and Federal law. The information contained herein and in any attachment is only for the use of the intended recipient. If you received this information in error, and/or you are not the intended recipient, you are advised that any disclosure, distribution, reproduction or any other use of this electronic information is prohibited. Please notify the sender of this electronic message immediately if you have received this information in error and destroy all electronic and hard copies of the communication, including attachments. Thank you for your assistance. When communicating, the best practice is to use the member s unique health plan ID number instead of name. All BND member ID numbers are randomly generated and do not contain, for example, part of the member's birthday or social security number. Reporting: Federal regulation requires the reporting of any breach of confidentiality. The law requires that each individual whose PHI was breached must be notified within 60 days of the breach (or awareness of the breach). Notify the health plan immediately by Hotline@universalcare.com; by fax to ; or by phone to ext Mandatory reporting must be within 5 days ($100 per day penalty) to the Office of Health Information Integrity. Monetary Penalties vary depending on the amount of information released, and the knowledge of the violator. If the violator did not know and should not have been expected to know of violation: min: $100 to $25,000 per violation and max: $50,000 to $1,500,000 per violation. Violator did know: $50,000 to $1,500,000 per violation. Prevention: Every plan and its FDR s must prevent the unlawful or unauthorized access, use, or disclosure of patients medical information ( strict liability ) by implementing appropriate administrative, technical, and physical safeguards to protect patient medical information. We all must reasonably safeguard confidential medical information from any unauthorized access or unlawful access, use or disclosure. It is against the law to sell member information (address, phone, , or any other member information). Identity Theft must also be prevented.

5 Brand New Day Medicare Mandated Training Page 5 of 9 Test Section E. 9) Plans and their FDR s are not responsible for implementing safeguards to protect patient information. 10) Plans and their FDR s must teach their staff and contracted entities about protecting member health and demographic information. 11) There is a $100 per day penalty for not reporting violations within 5 days. 12) If a member s information was accidentally released, the member must be notified within 60 days of the breach. 13) Whether a person knows or doesn t know about this law, there can be monetary penalties up to $1,500,000 for violations. Brand New Day Models of Care Brand New Day (BND) is a Health Maintenance Organization (HMO) that offers Special Needs Plans (SNPs; plans that are designed to take care of a specific population) and traditional Medicare plans. All of the plans include Medicare Advantage (Part A hospital and Part B professional services) as well as Prescription Drug coverage (Part D). Plans that offer Part A, B, and D benefits are called MAPDs. Brand New Day has the following MAPD plan types: Traditional MAPDs with $0 to low copayments for services. In addition to services covered under Medicare Part A and Part B, members receive benefits such as dental, vision, acupuncture, and unlimited transportation to plan-approved locations. D-SNP for Dual eligible members, Medi-Medi members To join this plan, an individual must have dual eligibility in both Medicare and Medi-Cal. Every member is assigned a caring Member Advocate to help coordinate and maximize benefits from the two government programs. BND Member Advocates help qualified members apply for services like In Home Supportive Services, (IHSS) Meals on Wheels, life-sustaining utility reimbursement, and free cell phone minutes from a federal program. Brand New Day provides medical and prescription drug benefits; vision and dental benefits; and unlimited transportation when approved for medical appointments. Members are also entitled to a free gym membership at their local gym. The Member Advocate helps the member schedule necessary appointments for preventive care to help our members stay healthy. When needed, BND physicians can send a field intervention nurse (FIN) to a member s home to help the member with medications, wound care, injections, health education, etc. BND has a web-based communications network through which the member s Care Team coordinates care between the providers who all share a single care plan to help the member reach his or her health goals. Chronic Care SNP (C-SNP) for members with Mental Illness To join this plan, an individual must have been diagnosed with Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, or Paranoid Disorder. In this model every member selects or is assigned to (and have direct unlimited access to) a Psychiatrist, Licensed Clinical Social Worker (LCSW), Life Coach (behavioral health case manager), and has a local drop-in Activity Center. Members enjoy recreation, socialization, job training, computer access, art, dance, exercise, individual and group therapy and classes at the Activity Center. There are monthly theme parties and a monthly

6 Brand New Day Medicare Mandated Training Page 6 of 9 field trip. The Life Coach helps the member schedule needed preventive care and accompanies the member to appointments as needed. All these services are at $0 copay. Brand New Day has vision and dental benefits as well as unlimited transportation when approved for medical appointments. Members are also entitled to a free gym membership at their local gym. Physicians, nurses, and even psychiatrists make home visits as needed. BND has a web-based communications network through which the member s Care Team coordinates care between the providers who all share a single care plan to help the member reach his or her health goals. Chronic Care SNP (C-SNP) for members with Diabetes To join this plan, an individual must have been diagnosed with Type II Diabetes. In this model each member is given an electronic cellular 2-way Glucometer that speaks multiple languages. The meter connects the member to a 24-hour Diabetes Counseling Center where a Certified Diabetic Educator receives immediate messages from the Glucometer when the member s sugar reading is at a dangerous level. The Counselor may call the member, the PCP, or other designated person. This enables the quickest response to the member s situation. The Glucometer, Insulin, test strips, and other diabetic supplies are furnished at no cost to the member. Each member is assigned a Health Coach to help the member schedule needed preventive care and specialist appointments. Members have vision and dental benefits as well as unlimited transportation when approved for medical appointments. BND has a webbased communications network through which the member s Care Team coordinates care between the providers who all share a single care plan to help the member reach his or her health goals. Depending on the specific Diabetes C-SNP plan the member chooses, one has a gym membership and the other has lower drug costs. Chronic Care SNP (C-SNP) for members with Dementia Each member is assigned a Health Coach to help the member and family / caregivers with the complex care for this member. Members also are assigned a Complex Care Nurse Manager to help coordinate care with the PCP, Neurologist, and other specialists that may be needed. An assessment is conducted upon enrollment to determine if there is a risk of falling as this is common for people with dementia and is often preventable. The Health Coach has many community resources and materials available to assist the family / caregivers. The Health Coach may assist in scheduling needed preventive care and specialist appointments. Members have vision and dental benefits as well as unlimited transportation when approved for medical appointments. BND has a web-based communications network through which the member s Care Team coordinates care between the providers who all share a single care plan to help the member reach his or her health goals. Depending on the specific Dementia C-SNP plan the member chooses, one has a gym membership and the other has lower drug costs. Chronic Care SNP (C-SNP) for members with Congestive Heart Failure (CHF) To qualify, beneficiaries must have been diagnosed as having Congestive Heart Failure and must be in treatment for it. CHF is a disease with many stages from the least severe to the greatest severity. Some physicians diagnose CHF when the member is in Stage A which includes one or more common conditions such as: hypertension, high blood pressure, coronary artery disease, metabolic syndrome, history of alcohol abuse, or history of rheumatic fever. Each member is assigned a Health Coach to help the member and family / caregivers with the complex care for this member. The Health Coach may assist in scheduling needed preventive care and specialist appointments. Members also are assigned a Complex Care

7 Brand New Day Medicare Mandated Training Page 7 of 9 Nurse Manager to help coordinate care with the PCP, Cardiologist, and other specialists that may be needed. An assessment is conducted upon enrollment to help the member s Interdisciplinary Care Team (ICT) develop an Individualized Care Plan (ICP) with / for the member. The Health Coach issues to the member a 2-way scale to monitor the member s weight. The scale connects to a center where especially trained care managers are ready to contact the member or PCP when the member s weight gain is greater than 2 lbs. in a day or 5 lbs in a week. Based on the member s conditions, Brand New Day may also send the member a blood pressure cuff to monitor blood pressure, or a pulse oximeter to monitor oxygen levels in the blood. The scale, cuff, and pulse oximeter are provided by BND at no cost to the member. Members have vision and dental benefits as well as unlimited transportation when approved for medical appointments. BND has web-based communications network through which the member s Care Team coordinates care between the providers who all share the ICP, thus helping the member reach his or her health goals. Depending on the specific CHF C-SNP benefit package that the member chooses, the member may have a gym membership. Member Advocate Member Advocates, Health Coaches, and Life Coaches D-SNP members A Member Advocate is a BND employee who is assigned to each D-SNP member. Member Advocates are responsible for coordinating and maximizing Medicare and Medi-Cal benefits, as well as helping the member navigate resources found in the community. Health Coach C-SNP members A Health Coach is a professional with some medical background. Health Coaches are assigned to each C-SNP member to help the member navigate plan benefits, focus on chronic care management, and stay on top of preventive care. Life Coach C-SNP for members with mental illness A Life Coach is a behavioral health case management professional assigned to each member in the C-SNP for mental illness. Life Coaches help members navigate plan benefits, focus on chronic care management, and stay on top of preventive care. Other Resources for Brand New Day Members Member Services Answering Service Nurse Advice Line All members All members All members Any member may call our Member Services Department for best friend service during our open hours. After hours, our answering service fields calls that can t wait until the next day. Nurses are available around the clock to provide clinical advice.

8 Brand New Day Medicare Mandated Training Page 8 of 9 Test Section F. 14) Brand New Day has traditional Medicare Advantage Part D (MAPD) plans and a variety of Special Needs Plans (SNPs.) 15) The BND D-SNP has an unlimited transportation benefit for members. 16) The C-SNP for Mental Illness includes a psychiatrist, PCP, Life Coach, LCSW, and Activity center at no cost to the member. 17) The C-SNP for Diabetes gives each member a 2-way cellular Glucometer that alerts a Diabetic Call Center when a member s blood sugar reading is at a dangerous level. 18) Each member in the C-SNP for Diabetes has a Member Advocate assigned to help the member. 19) The C-SNP for Diabetes charges members high copayments for the Glucometer, Insulin, and Diabetic Supplies. 20) Depending on the specific Dementia C-SNP plan the member chooses, one has a gym membership and the other has lower drug costs. 21) The Dementia C-SNP has many community resources and materials available to assist the family / caregivers. 22) To qualify for the CHF C-SNP members must have been diagnosed by a physician with CHF (at any stage) and must be in treatment for CHF. 23) Each Congestive Heart Failure C-SNP member is assigned to a psychiatrist and a social worker. 24) The CHF Health Coach issues a 2-way scale to members so a care management center can monitor the member s weight gain and call the member or PCP as needed. 25) The scale, blood pressure cuff, and pulse oximeter will cost the CHF C-SNP member a great deal of money. Quality Improvement Program In accordance with Medicare requirements and guidelines, Brand New Day (BND) has a robust Quality Improvement Program. The program includes but is not limited to the following: Medication Therapy Management Program (MTMP) Members with polypharmacy, co-occurring chronic conditions, and a drug spend over $750 in any quarter are enrolled into the MTMP. They may opt out but are encouraged to participate in a comprehensive medication review (CMR) with a pharmacist or other qualified provider. The purpose of the review is for safety purposes and to reduce costs when appropriate. Members enrolled remain in the program the entire year. Chronic Care Improvement Project (CCIP)

9 Brand New Day Medicare Mandated Training Page 9 of 9 Each SNP must submit a CCIP specific to its special needs population. At least one CCIP per SNP must contribute to the Medicare national initiative, The Million Hearts Campaign, to reduce cardiac events. BND reports measurements, interventions, and findings to Medicare annually. BND CCIP topics include: Control HbA1c to Reduce Cardiovascular Disease and to Reduce Cardiovascular Events Increase Statin Use in Perosns with Diabetes to Reduce Cardiac Events and Prevent or Slow the Progression of Chronic Kidney Disease (CKD) Quality Improvement Project (QIP) Each SNP must submit a QIP specific to its special needs population. BND reports measurements, interventions, and findings to Medicare annually. BND QIP topcis include: Reduce Hospital Readmissions Through Appropriate, Timely, and Complete Transition of Care (TOC) Processes Increase the Number of Members who had an Acute Inpatient Discharge or ED Visit and who were Dispensed Appropriate Medications (Systemic Corticosteroid and/or a Bronchodilator) HEDIS Preventive Care Measures Brand New Day and its providers are required to participate in the HEDIS preventive care screening measures and in measures that monitor how a provider controls certain conditions (LDL, Diabetes, and Blood pressure). Medicare awards STARs to plans based on a 5-STAR system. Plans strive to be 4 or 5 STAR Plans. Test Section G. 26) Brand New Day has a robust Quality Improvement Program. 27) Medication Therapy Management increases costs and decreases safety. 28) One BND CCIP aims to control HbA1c to reduce cardiovascular disease. 29) One BND QIP aims to reduce avoidable hospital readmissions. 30) Providers don t have to participate in HEDIS data collection. I hereby attest that I have completed the foregoing mandated training in the form of this study guide and test. I understand that if I have questions at any time I may go to the Brand New Day Compliance Department staff or the Compliance Officer to seek guidance and clarification. Furthermore, I understand that failure to comply with State and Federal requirements will result in disciplinary action commensurate to the infraction including the possible termination of services from the company if appropriate. I understand that no one is exempt from these requirements. Name Dept. Signature Date