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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAHCCCS MAO Certification Policy Update | OpenPayer
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    CurrentArizona Health Care Cost Containment SystemPolicy 313

    Certification of Medicare Advantage Organizations Serving Dual Eligible AHCCCS Members

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    Governs AHCCCS state certification of Medicare Advantage Organizations and D-SNPs serving dual-eligible members, including application, financial viability, monitoring, and reporting requirements for ACC, ALTCS/EPD, and RBHA Contractors.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyCertification of Medicare Advantage Organizations Serving Dual Eligible AHCCCS Members
    Policy CodePolicy 313
    Change TypeClarification and revision
    Effective DateOctober 1, 2018
    Next Review DateNot specified
    Key ActionSubmit the CMS State Certification Request Form and Specific Plan of Action at least 30 calendar days before the CMS submission deadline.
    SourceLink
    POLICY UPDATE CHANGES

    The policy title and related terminology were clarified to refer to Medicare Advantage Organizations rather than Medicare Advantage Plans.

    Definitions for Affiliated Organization, Medicare Advantage Organization, and State Certification Request Form were added or expanded.

    Contractor submission requirements were revised to require a State Certification Request Form and Specific Plan of Action at least 30 calendar days before the form is due to CMS.

    Financial viability, monitoring, and reporting requirements were consolidated and clarified for the Medicare Advantage line of business.

    30 daysMinimum submission lead time

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2 weeksAHCCCS initial response
    1 monthPerformance bond
    Quarterly + annualFinancial reporting
    2Certification authorities

    AHCCCS Certification Requirements

    AHCCCS MAO certification requirements

    AHCCCS certification requires satisfaction of all organizational eligibility, submission, financial viability, review, and ongoing reporting requirements below.

    ALL of the following

    • Organizational eligibility

      • The applicant is an existing AHCCCS Medicaid Contractor serving the same Geographic Service Area (GSA) for which certification is requested.

    • Timely submission

      • Submit the CMS State Certification Request Form to the AHCCCS DHCM Medicare Operations Compliance Officer for Medicare.At least 30 calendar days before the form is due to CMS
      • Submit the Specific Plan of Action to AHCCCS at the same time as the State Certification Request Form.

      • The Specific Plan of Action addresses

        • MAO start-up timing, coincident with the first proposed Medicare Advantage Contract Year start date.
        • The GSA or GSAs for which certification is requested.
        • Projected MAO enrollment for each proposed D-SNP at start-up and at the end of the first proposed Medicare Advantage Contract Year, by GSA.
        • The projected amount of, and how the separate MAO line of business will meet, equity-per-member requirements initially and on an ongoing basis, in accordance with ACOM Policy 305.
        • The projected amount of, and how the separate MAO line of business will meet, performance bond requirements initially and on an ongoing basis, in accordance with ACOM Policy 305.
        • An understanding of the ongoing, separate financial viability, monitoring, and reporting requirements for each D-SNP offered to dual-eligible members.

    • AHCCCS review and approval

      • AHCCCS notifies the plan of specific financial viability requirements or requests additional information needed to review and approve the request.Within two weeks after receipt of the State Certification Request Form
      • The applicant demonstrates that it can comply with equity-per-member and performance-bond requirements through the Specific Plan of Action.
      • AHCCCS reviews and accepts the Specific Plan of Action, obtains the required final signature, and returns the executed State Certification Request Form to the Contractor for submission to CMS.

    • Financial viability and ongoing reporting

      • The Contractor remains in compliance with current AHCCCS contractual financial viability, claims, and administrative standards.
      • The Contractor obtains and maintains a performance bond specifically for the MA Plan in accordance with ACOM Policy 305.One month's capitation or an established amount per enrolled member, subject to ACOM Policy 305
      • The Contractor maintains equity per Medicare Advantage dual-eligible member in accordance with ACOM Policy 305.
      • The Contractor self-monitors compliance with equity-per-member and performance-bond requirements.
      • The Contractor reports impending noncompliance to AHCCCS with a corrective action plan.

    Key Submission and Financial Requirements

    Certification submission lead time
    Required materialsCMS State Certification Request Form and Specific Plan of Action
    Submission lead timeAt least 30 calendar days before the State Certification Request Form is due to CMS
    Submission destinationAHCCCS Division of Health Care Management Medicare Operations Compliance Officer for Medicare
    AHCCCS initial response
    Response periodWithin two weeks after receipt of the State Certification Request Form
    AHCCCS notificationDHCM will notify the plan of the specific financial viability requirements
    Additional information

    Contractor Certification Actions

    Note

    Select the State Certification Authority

    Before applying, select the appropriate Arizona certification pathway. AHCCCS may certify an MAO serving only dual-eligible members, while the Arizona Department of Insurance (DOI) may license Contractors serving dual-eligible members instead. DOI certification is required when the MAO serves Medicare beneficiaries who are not dual eligible, and for stand-alone Medicare Part D Prescription Drug Plans (PDPs).

    • A Contractor may request DOI licensure instead of AHCCCS certification when serving dual-eligible members.
    • For a State-contracted MAO offering a D-SNP to dual-eligible members enrolled in DES/DDD, certification may be extended to include that population.
    Documentation Required

    Meet AHCCCS Contractor and GSA Eligibility Requirements

    AHCCCS will certify a Contractor only when it is currently an AHCCCS Medicaid Contractor in the same Geographic Service Area (GSA) for which certification is requested. A conditional certification may be available during the AHCCCS bid process for a new contracting cycle, but it depends on being awarded a contract in that GSA.

    Policy Definitions

    Affiliated Organization
    RelationshipA party that controls, is controlled by, or is under common control with an entity
    Control structureControl may be direct or indirect through one or more intermediaries
    SynonymCorporate affiliate
    Centers for Medicare and Medicaid Services (CMS)
    Federal departmentAn organization within the United States Department of Health and Human Services
    Medicare administrationAdministers the Medicare program under Title XVIII
    Other programs
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyCertification of Medicare Advantage Organizations Serving Dual Eligible AHCCCS Members
    Policy CodePolicy 313
    Change TypeClarification and revision
    Effective DateOctober 1, 2018
    Next Review DateNot specified
    Key ActionSubmit the CMS State Certification Request Form and Specific Plan of Action at least 30 calendar days before the CMS submission deadline.
    SourceLink
    On This Page
    AHCCCS Certification RequirementsKey Submission and Financial RequirementsContractor Certification ActionsPolicy Definitions
    The Contractor submits financial data for the MA Plan line of business separately using the applicable AHCCCS Financial Reporting Guide.

    Required reporting consists of quarterly financial statements and an annual audit report with supplemental financial schedules.

    DHCM will determine whether additional information is necessary to review and approve the request
    Performance bond amount
    General amountOne month's capitation
    Alternative amountAn established amount per enrolled member
    Applicable policyRefer to ACOM Policy 305 for further clarification
    Financial reporting frequency
    Quarterly reportingQuarterly financial statements
    Annual reportingAn annual audit report
    Supplemental materialsSupplemental financial schedules reporting on the Medicare Advantage plan line of business separately
    • Confirm an existing AHCCCS Medicaid Contractor relationship in the applicable GSA.
    • Conditional approval may allow the Offeror to begin the MAO process before the new contract is awarded.
    • Conditional approval for a GSA is revoked if the Offeror is not awarded a contract for that GSA in the new contracting period.
    Documentation Required

    Submit Certification Materials

    For AHCCCS certification, submit the CMS State Certification Request Form to the AHCCCS Division of Health Care Management (DHCM), Medicare Administrator/Operations Compliance Officer for Medicare, no later than 30 calendar days before the form must be sent to the Centers for Medicare & Medicaid Services (CMS). Obtain the form through the annual Medicare Advantage application on the CMS website and submit the Specific Plan of Action to AHCCCS at the same time.

    • Recipient: AHCCCS DHCM Medicare Administrator/Operations Compliance Officer for Medicare.
    • Timing: at least 30 calendar days before the State Certification Request Form is due to CMS.
    • Source: the annual Medicare Advantage application available at www.cms.gov.
    • Include the Specific Plan of Action with the certification request.
    Documentation Required

    Prepare the Specific Plan of Action

    Prepare the Specific Plan of Action in narrative form and submit it with the State Certification Request Form. The plan must explain the MAO’s start-up, service area, enrollment, financial equity, performance bond, and ongoing reporting commitments.

    • Timing of MAO start-up, coinciding with the first proposed Medicare Advantage Contract Year start date.
    • GSA(s) for which certification is requested.
    • Projected enrollment for each proposed D-SNP at start-up and at the end of the first proposed Medicare Advantage Contract Year, by GSA.
    • Projected amount of and approach for meeting separate MAO line-of-business equity-per-member requirements initially and on an ongoing basis, consistent with ACOM Policy 305.
    • Projected amount of and approach for meeting separate MAO line-of-business performance bond requirements initially and on an ongoing basis, consistent with ACOM Policy 305.
    • Statement acknowledging ongoing separate financial viability, monitoring, and reporting requirements for each D-SNP, as established in the applicable contract and AHCCCS Financial Reporting Guide for the related line of business.
    Billing Rule

    Maintain Ongoing Financial Compliance

    Maintain compliance after certification. The Contractor must satisfy current AHCCCS financial viability, claims, and administrative standards; maintain MA Plan-specific performance bond and equity-per-member requirements; monitor compliance; and provide required financial reporting.

    • Obtain and maintain a performance bond specifically for the MA Plan under ACOM Policy 305.
    • Maintain equity per MA dual-eligible member under ACOM Policy 305.
    • Self-monitor equity-per-member and performance bond compliance.
    • Notify AHCCCS when approaching non-compliance and submit a corrective action plan.
    • AHCCCS may investigate issues brought to its attention concerning the MA Plan.
    • Submit quarterly financial statements and an annual audit report with supplemental financial schedules reporting the MA Plan line of business separately.
    • Report financial data using the applicable AHCCCS Financial Reporting Guide for the related line of business.
    Administers Medicaid under Title XIX and the State Children's Health Insurance Program under Title XXI
    Dual Eligible Member
    Medicaid enrollmentEnrolled with an AHCCCS Contractor for full Medicaid services
    Medicare statusAlso a Medicare beneficiary; these persons are considered full dual eligible members
    ExclusionsDoes not include QMB-only, SLMB-only, or QI-1 Medicare Cost Sharing populations
    Dual Eligible Special Needs Plan (D-SNP)
    Plan typeA type of Medicare Advantage plan offered by a CMS-contracted MAO
    Enrollment limitLimits enrollment to beneficiaries entitled to both Medicare and Medicaid benefits
    ProgramsMedicare Title XVIII and Medicaid Title XIX
    Equity per Member
    NumeratorNet assets that are not designated or restricted for specific purposes
    DenominatorThe number of Medicare Advantage Dual Eligible Members
    ClarificationRefer to ACOM Policy 305 for further clarification
    Medicare Advantage Organization (MAO)
    Entity typeA public or private entity organized and licensed by a state as a risk-bearing entity
    ExceptionProvider-sponsored organizations receiving waivers are excepted
    Federal certificationCertified by CMS as meeting Medicare Advantage contract requirements
    Medicare Advantage Contract Year
    Contract termA one-year CMS Medicare Advantage program contract term
    Beginning dateJanuary 1
    Ending dateDecember 31 of each calendar year
    Medicare Advantage Plan
    CoverageHealth benefits coverage offered under a policy or contract by a Medicare Advantage Organization
    Benefits and premiumIncludes a specific set of health benefits offered at a uniform premium
    Cost-sharing and scopeProvides a uniform level of cost-sharing to all Medicare beneficiaries residing in the service area; a D-SNP is a defined type of Medicare Advantage plan
    State Certification Request Form
    Form statusA form required by CMS and completed by the applicable state agency
    AttestationAttests that an MAO applicant is a public or private entity organized and licensed by the state as a risk-bearing entity
    TimingIncluded in the annual Medicare Advantage application and returned to the applicant before the CMS application deadline
    Medicare Advantage Prescription Drug/Special Needs Plan (MA-PD/SNP)
    OrganizationAn organization providing Medicare services to Medicare beneficiaries under a Medicare risk contract with CMS
    Benefit scopeProvides the full Medicare benefit, including prescription drugs
    Specific groupsMay serve dual eligibles and/or members residing in nursing facilities
    Performance Bond
    InstrumentA surety instrument
    PurposeProvides a financial guarantee to AHCCCS
    AmountOne month's capitation or an established amount per enrolled member; refer to ACOM Policy 305 for further clarification