CurrenthometownhealthprovidersPolicy Hometown.HCP.001

Compliance Policies & Procedures

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Governs the Hometown Health Compliance Program and related policies that apply to Hometown Health staff, Board members, first‑tier/downstream/related entities, and network providers across Medicare Advantage, Part D, commercial and other sponsor plans.

Policy Summary

Payerhometownhealthproviders

PolicyCompliance Policies & Procedures

Policy CodePolicy Hometown.HCP.001

Change TypeNo material change

Effective DateMay 1, 2018

Last ReviewApr 28, 2017

Next Review DateMay 1, 2020

Key ActionNo specific authorization rules are defined; the policy establishes compliance program oversight across product lines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MA/Part C/Part D & commerciallines of business covered

annualminimum review frequency

90 daysavailability to new employees

4 groupspopulations in scope

Applicability & Governance

Compliance Program applicability and governance

Applicability and program governance

Applies to Hometown Health staff (management, staff, contractors, vendors), Board members, officers and managers, first‑tier/downstream/related entities (FDR) as defined by CMS, and network providers, in the same manner and to the extent set forth in Hometown Health policies and procedures.

Scope covers MA/Part C, PDP/Part D, EGWP and other commercial products.

Program governance: The Program is developed by the Hometown Health Compliance Manager and approved by the Renown Health Corporate Compliance Officer.

Policy review and revisions: Program policies and procedures are reviewed at least annually by the Hometown Health Compliance Manager in conjunction with the Renown Health Corporate Compliance Officer; revisions include material changes to applicable State and Federal laws, regulations, statutes, and Program guidance.

Availability: Program policies and procedures will be made available to all employees within 90 days of hire and on an ongoing basis.

Point of contact and notifications: Hometown Health notifies delegated contractors of compliance‑impacting changes; inquiries about the Program should be directed to the Hometown Health Manager of Compliance.

Codes & Regulatory References

Not applicablemixed

No codes listed

Regulatory references

Key federal regulatory citationsFederal Register Vol. 64, No. 219 (Nov 15, 1999) — OIG Compliance Program Guidance for Medicare+Choice Organizations; Prescription Drug Benefit Manual, Chapter 9; Medicare Advantage Program, 42 C.F.R. Part 422; Medicare Managed Care Manual, Chapter 21; Voluntary Medicare Prescription Drug Benefit, 42 C.F.R. Part 423; Requirements Relating To Health Care Access, 45 C.F.R. Subtitle A, Subchapter B; DOJ Criminal Division, Fraud Section evaluation guidance.

State regulatory citations (Nevada)Nevada Revised Statutes governing commercial insurance regulations, Title 57, Chapters 679A through 689C.

Internal policy referencesRENOWN.CCD.025 - Disciplinary Action and Programmatic Corrections.

Accreditation / standards referencedURAC Health Plan CORE Standard P-CORE 4 - Regulatory Compliance; URAC Health Plan Standard P-CP 1 - Compliance Program: Internal Controls.

Guidance and manualsPrescription Drug Benefit Manual, Chapter 9 ('Compliance Program Guidelines'); Medicare Managed Care Manual, Chapter 21 ('Compliance Program Guidelines').

Provider Impact & Scope

Note

Compliance program scope — no specific authorization or billing rules

This administrative policy establishes the Hometown Health Compliance Program and its oversight responsibilities across product lines (including MA/Part C, PDP/Part D, EGWP, commercial and other sponsor plans) but does not set or require any specific prior authorization, billing, denial‑risk, or clinical documentation rules. Providers and delegated entities should follow applicable operational policies and contract terms for authorization and billing; this policy defines program scope, governance, review cadence, and notification obligations rather than clinical authorization criteria.

Applies to Hometown Health staff, Board members/officers/managers, first‑tier/downstream/related entities, and network providers as described in the scope.
Program is part of Renown Health Corporate Compliance and implements oversight across MA, PDP/Part D, EGWP and commercial product lines.
This policy does not establish coverage determinations, prior‑authorization, billing, denial‑risk or documentation requirements.

Key Terms

CMS — Centers for Medicare and Medicaid Services

DefinitionCenters for Medicare and Medicaid Services ('CMS'): The federal agency that administers the Medicare program and works to ensure beneficiaries receive high quality health care.

Websitehttps://cms.gov/.

Context of useReferenced throughout the Compliance Program as the federal regulator for MA and Part D program requirements.

Downstream Entity

DefinitionDownstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with a MA organization or Part D benefit, below the level of the arrangement between the MA organization (or applicant) or Part D plan sponsor (or applicant) and a first‑tier entity. These written arrangements continue down to the ultimate provider of health and administrative services (42 C.F.R. §§422.2, 423.4).

Regulatory citation42 C.F.R. §§422.2, 423.4.

RoleCovers parties at sub‑first‑tier levels that perform health or administrative services for MA/Part D beneficiaries.

EGWP — Employer Group Waiver Plan

DefinitionEmployer Group Waiver Plan ('EGWP'): A group Medicare Part D prescription drug plan option offered to retirees who have been promised prescription drug coverage as part of their Other Post‑Employment Benefits (OPEB).

ContextEGWPs provide Part D drug coverage to retiree groups as an alternative to individual Part D enrollment.

Referenceegwpinfo.com (informational reference in source).

First‑Tier Entity

DefinitionFirst‑Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with a MA organization or Part D plan sponsor (or applicant) to provide administrative services or health care services to a Medicare‑eligible individual under the MA or Part D program (42 C.F.R. §§422.2, 423.4).

Regulatory citation42 C.F.R. §§422.2, 423.4.

ScopeApplies to entities that contract directly with the MA organization or Part D sponsor to perform covered services.

Medicare Advantage (MA / Part C)

DefinitionMedicare Advantage ('MA' or 'Part C'): A Medicare program that provides additional choices among health plans for individuals enrolled in Medicare Parts A and B; known also as Medicare + Choice Plans. (ESRD exceptions apply in certain circumstances).

Eligibility noteThose who subscribe to Medicare Parts A and B are eligible, except individuals with End‑Stage Renal Disease (ESRD) unless exceptions apply.

Relation to drug coverageMA plans may include prescription drug coverage as an alternative to Prescription Drug Plans (Part D).

Prescription Drug Plan (PDP / Part D)

DefinitionPrescription Drug Plan ('PDP' or 'Part D'): A Medicare program to assist with the cost of prescription drugs for eligible Medicare beneficiaries; drug coverage may be obtained either through a PDP or through an MA plan that includes drug coverage.

Coverage pathwaysTwo ways to obtain Medicare prescription drug coverage: 1) through a Medicare Prescription Drug Plan (PDP) or 2) through a Medicare Advantage Plan that includes drug coverage.

Offered byOffered by insurance companies and other private companies approved by Medicare.

Related Entity

DefinitionRelated Entity: Any entity that is related to an MA and/or Part D sponsor by common ownership or control.

ImplicationRelated entities are within the Compliance Program scope where common ownership or control links them to the sponsor.

Use in governanceReferenced for determining applied oversight and reporting obligations under Hometown Health compliance policies.

Policy Summary

Payerhometownhealthproviders

PolicyCompliance Policies & Procedures

Policy CodePolicy Hometown.HCP.001

Change TypeNo material change

Effective DateMay 1, 2018

Last ReviewApr 28, 2017

Next Review DateMay 1, 2020

Key ActionNo specific authorization rules are defined; the policy establishes compliance program oversight across product lines.

SourceLink

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Compliance Policies & Procedures

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Sign up for hometownhealthproviders Policy Hometown.HCP.001 alerts

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Applicability & Governance

Compliance Program applicability and governance

Applicability and program governance

Scope covers MA/Part C, PDP/Part D, EGWP and other commercial products.

Program governance: The Program is developed by the Hometown Health Compliance Manager and approved by the Renown Health Corporate Compliance Officer.

Availability: Program policies and procedures will be made available to all employees within 90 days of hire and on an ongoing basis.

Codes & Regulatory References

Not applicablemixed

No codes listed

Regulatory references

State regulatory citations (Nevada)Nevada Revised Statutes governing commercial insurance regulations, Title 57, Chapters 679A through 689C.

Internal policy referencesRENOWN.CCD.025 - Disciplinary Action and Programmatic Corrections.

Accreditation / standards referencedURAC Health Plan CORE Standard P-CORE 4 - Regulatory Compliance; URAC Health Plan Standard P-CP 1 - Compliance Program: Internal Controls.

Guidance and manualsPrescription Drug Benefit Manual, Chapter 9 ('Compliance Program Guidelines'); Medicare Managed Care Manual, Chapter 21 ('Compliance Program Guidelines').

Provider Impact & Scope

Note

Compliance program scope — no specific authorization or billing rules

Applies to Hometown Health staff, Board members/officers/managers, first‑tier/downstream/related entities, and network providers as described in the scope.
Program is part of Renown Health Corporate Compliance and implements oversight across MA, PDP/Part D, EGWP and commercial product lines.
This policy does not establish coverage determinations, prior‑authorization, billing, denial‑risk or documentation requirements.

Key Terms

CMS — Centers for Medicare and Medicaid Services

DefinitionCenters for Medicare and Medicaid Services ('CMS'): The federal agency that administers the Medicare program and works to ensure beneficiaries receive high quality health care.

Websitehttps://cms.gov/.

Context of useReferenced throughout the Compliance Program as the federal regulator for MA and Part D program requirements.

Downstream Entity

Regulatory citation42 C.F.R. §§422.2, 423.4.

RoleCovers parties at sub‑first‑tier levels that perform health or administrative services for MA/Part D beneficiaries.

EGWP — Employer Group Waiver Plan

ContextEGWPs provide Part D drug coverage to retiree groups as an alternative to individual Part D enrollment.

Referenceegwpinfo.com (informational reference in source).

First‑Tier Entity

Regulatory citation42 C.F.R. §§422.2, 423.4.

ScopeApplies to entities that contract directly with the MA organization or Part D sponsor to perform covered services.

Medicare Advantage (MA / Part C)

Eligibility noteThose who subscribe to Medicare Parts A and B are eligible, except individuals with End‑Stage Renal Disease (ESRD) unless exceptions apply.

Relation to drug coverageMA plans may include prescription drug coverage as an alternative to Prescription Drug Plans (Part D).

Prescription Drug Plan (PDP / Part D)

Coverage pathwaysTwo ways to obtain Medicare prescription drug coverage: 1) through a Medicare Prescription Drug Plan (PDP) or 2) through a Medicare Advantage Plan that includes drug coverage.

Offered byOffered by insurance companies and other private companies approved by Medicare.

Related Entity

DefinitionRelated Entity: Any entity that is related to an MA and/or Part D sponsor by common ownership or control.

ImplicationRelated entities are within the Compliance Program scope where common ownership or control links them to the sponsor.

Use in governanceReferenced for determining applied oversight and reporting obligations under Hometown Health compliance policies.