Are you worried that you’re not meeting the standards set forth by the CMS (Centers for Medicare and Medicaid Services) regarding Medicare? Since there are punishments and fines associated with not conforming to CMS compliance standards, you need to make sure that you are doing everything you can to be compliant with the federal agency.

The stakes are high to be compliant considering that 18.5% of the US population is on Medicare. Luckily, we are here to help.

So, what are the most important things that you need to be aware of for Medicare compliance? How difficult is it to meet all of these compliance standards? 

This is your guide. 

Affordable Care Act 

Let’s start by talking about one of the most controversial subjects in healthcare. This would be the Affordable Care Act, otherwise known as Obamacare. 

It was implemented in 2010 and it requires that every adult in the United States purchase health insurance or find a program that would help them get such insurance. However, it allowed people to stay on their parent’s health insurance up until the age of 26. 

This arguably created some financial pressure for some people to obtain health insurance. On the other side, it also virtually guaranteed that no insurance company could deny coverage to someone if they happened to have a pre-existing health condition. 

Where the Affordable Care Act becomes an issue is consistent enforcement throughout each state. The truth is that some states either do not have the authority to enforce certain parts of this act or they are simply just not willing to. 

The following four states have told CMS that they are not enforcing the provisions of the Affordable Care Act: 

  • Wyoming
  • Texas
  • Oklahoma
  • Missouri 

So, what does that mean for CMS and these four states? It means that these states are leaving it up to CMS to be the full authority to enforce these measures. 

The Final Rule 

CMS recently put new compliance rules for Medicare that they called “The Final Rule.” This went into effect on June 28, 2022, and the rule was targeted at third-party marketing companies that are involved in selling Medicare plans. 

This is specifically aimed at third-party marketing organizations, better known as TPMOs. CMS has decided to alter the definition of TPMO. Under this Final Rule, a TPMO will be considered an organization that is paid to perform certain duties related to Medicare enrollment such as lead generation, marketing, and sales. 

The second part of this rule involves TPMOs implementing a standard disclaimer for these Medicare plans. What this means is that TPMOs will have to let their clients know that these plans may not automatically cover them for their specific situations. 

Most TPMOs do not offer every available plan in a certain area. They will have to openly tell this to their clients instead of signing them on first only for them to find out that the TPMO does not have the plan that they are looking for. 

The third part of the Final Rule includes much stricter oversight over the TPMOs and making them required to adhere to any part of the Medicare plan that they agreed to with a client. 

Along with this, TPMOs will also have to notify beneficiaries of these plans plus disclose any subcontracted relationships that impact these plans for clients. 

Getting Compliant as an FDR 

So, one question is how do you get compliant with CMS if you are an FDR (first tier, downstream, or related entity)? Well, it is not as hard as you might think. Just make a checklist with the information down below and make sure that you are doing all of these things. 

The first two things that you should have as an FDR are a code of conduct policy and general compliance education and training. These programs can allow the people that work with you to understand exactly what the rules are plus what is expected of them. It also allows you to go over the compliance regulations together and make people understand them as a group. 

Next, you need to be aware of federal and state compliance obligations. This is going to depend on what part of the country you are operating from, so do some additional research on those regulations. It may be possible that your state does not even have such regulations if you are for example located in Texas. 

Along with the above, you have to make employees aware of reporting mechanisms and report the use of any offshore operations. Keeping track of the latter can avoid a slippery slope and keep any potential long-term trouble at bay if it is something that is addressed immediately. 

However, being compliant alone is not enough. You have to maintain evidence that you are being compliant. What this means is that you have to keep paperwork of your compliance as supporting evidence for at least the last decade of business. 

CMS takes certain measures to oversee these organizations every year and makes sure that they are complying with the regulations. If they are not, they risk losing their contracts. 

Make Sure You Have CMS Compliance 

These are just three of the main things that you need to be aware of when it comes to CMS compliance. The Affordable Care Act may be left up to CMS in some states, but you need to make sure you know the basic compliance regulations for FDRs and TPMOs along with the new Final Rule. 

Do you need to know more information? Visit our website to learn more today.