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Medicare Compliance for First Tier, Downstream and Related Entities (FDRs):  Informative. Educational. Valuable.

What we believe. Who you represent.

Our reputation of high standards for business integrity and ethical business conduct is one of our most valuable assets in our partnership with you. We are committed to legal and ethical conduct as an integral part of the operation of our business. Our reputation and success is not only dependent upon our conduct but also on the conduct and judgment of the individuals on whom we rely for products and services that support our organization’s purposes.

Are you a FDR?

If CareFirst Medicare Advantage has entered into a contract with your organization to provide administrative or health care services for our members on our behalf than you are a FDR.

CareFirst Medicare Advantage maintains the ultimate responsibility for fulfilling the terms and conditions of its contract with the Centers for Medicare and Medicaid Services (CMS) and for meeting all Medicare Program requirements. As a result, CMS holds CareFirst Medicare Advantage accountable for the actions and inactions of its FDRs who are delegated to provide administrative and/or health care services to CareFirst Medicare Advantage enrolled members.

Some examples of delegated functions may include, but are not limited to:

  • Sales & Marketing
  • Utilization Management
  • Quality Improvement
  • Application Processing
  • Enrollment, disenrollment, membership functions
  • Claims administration, processing and coverage adjudication
  • Appeals and grievances
  • Licensing and Credentialing
  • Pharmacy benefit management
  • Customer service
  • Provider network management
  • Processing of pharmacy claims at point of sale
  • Negotiation with prescription drug manufacturers and others for rebates, discounts or other price concessions on prescription drugs
  • Administration and tracking of enrollees’ drug benefits, including TrOOP balance processing
  • Coordination with other benefit programs such as Medicaid, state pharmaceutical assistance or other insurance programs
  • Health Care Services

CareFirst Medicare Advantage will provide full oversight of all FDRs through monitoring and external audits to ensure that all FDRs are in compliance with their contracts and all Medicare Program requirements.

Definitions of First Tier, Downstream and Related Entity

First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MA organization or applicant to provide administrative services or health care services for a Medicare eligible individual under the MA program

Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit, below the level of the arrangement between an MA organization (or applicant) and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.

Related Entity: any entity that is related to the MA organization by common ownership or control and (1) performs some of the MA organization's management functions under contract or delegation; (2) furnishes services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials to the MA organization at a cost of more than $2,500 during a contract period.

Failure to Comply with Medicare Program Requirements

If areas of noncompliance are determined, enforcement actions may be taken to both cure the deficiency and prevent future occurrences. Enforcement actions, such as corrective action plans and/or contract termination, may vary depending upon the severity of the issue.

As expressed within the Code of Ethical Business Conduct and Compliance for First Tier, Downstream and Related Entities, it is expected that you ensure timely, consistent, and effective enforcement through well-publicized disciplinary standards (e.g., mandatory retraining, termination, etc.) that are taken with any personnel within your organization who demonstrate any non-compliant or fraudulent behavior. As CareFirst Medicare Advantage FDR, you are expected to enforce completion of these requirements with your Downstream and/or Related Entities, as well.

If you are aware of or suspect noncompliant, unethical or illegal behavior by others, including, but not limited to, failure to complete the required training and education, you are obligated to report it to CareFirst Medicare Advantage.

Offshore Operations and Reporting

To make sure we comply with applicable Federal and State laws, rules and regulations, you’re prohibited from using any individual or entity (Offshore entity) to perform services for CareFirst Medicare Advantage’s Medicare plans. You must notify us immediately if you plan to use an offshore entity.