Select Health Medicare Compliance Program
Select Health is committed to operating a health plan that meets the requirements of all applicable laws and regulations of the Medicare Advantage and Part D programs.
Helping People Live the Healthiest Lives Possible
Select Health has a compliance program that is effective in preventing, detecting, and correcting Medicare Advantage and Part D program non-compliance as well as program fraud, waste, and abuse. Our compliance program is evaluated regularly based on CMS’ seven elements of an effective compliance program.
We have a Compliance Hotline available to our members, employees, and contractors 24 hours per day and seven days per week. The Compliance Hotline is the method for each of these groups to report suspected program non-compliance or potential fraud, waste, or abuse. Anonymity and interpretation services are available. If you believe you have observed or been subjected to Medicare program non-compliance or fraud, waste, or abuse, you should contact the Compliance Hotline at 800-442-4845.
Information about Select Health Medicare First Tier, Downstream, and Related Entities (FDRs)
Select Health relies on our contracted providers and other contractors to help us meet the needs of our members. These individuals and organizations are considered First tier, Downstream, and Related Entities (FDRs). FDRs provide health or administrative services to the Select Health Medicare members and are a vital part of this Medicare Advantage program. They have specific responsibilities under the Medicare guidelines, including:
- FDRs are required to comply with all applicable statutory, regulatory, and other Part C or Part D requirements, including adopting their own effective compliance programs.
- FDRs have a duty to report any violations of law; issues of program non-compliance; or fraud, waste, and abuse (FWA). Reports can be made to the Compliance Hotline at 800-442-4845. The Compliance Hotline is available 24 hours, seven days a week. Anonymity and interpretation services are available.
- FDRs have a duty to follow their organization’s Code of Conduct that articulates the commitment standards of conduct and ethical rules of behavior. See the Code of Conduct that Select Health and its employees commit to.
- FDRs are required to either provide the Select Health Code of Ethics or their own equivalent Code of Conduct to all of their employees as well as any downstream and related entities that support the Select Health Medicare Advantage program. These organizations must provide the applicable Code of Ethics/Conduct to their employees initially upon hire (or effective date of a contract) and annually thereafter.
- FDRs are required to complete General Compliance and FWA training courses based on CMS regulations. Trainings must be provided initially upon hiring an employee and annually thereafter if the employee’s work supports the Select Health Medicare Advantage program.
- FDRs may use the Select Health Compliance and FWA Training, CMS’ standardized FWA and General Compliance training, or substitute equivalent versions. (link to Pace for training registration or provide downloadable version)
- FDRs are required to maintain evidence of completion for no less than ten (10) years. Select Health and/or CMS may request evidence of completion from your organization for these courses. Evidence may include training logs with dates and certificates of completion, sign-in sheets, attestations, or other methods to demonstrate fulfillment of the obligation. CMS has a sample Certificate of Completion that is recommended for use or Select Health has developed a Sample Training Log that may also be used.
- FDRs may not be on, employ individuals who are on, or contract with individuals or entities who are on the Office of Inspector General List of Excluded Individuals and Entities (LEIE) or on the General Services Administration Excluded Parties Lists System (EPLS). The exclusion lists must be checked initially upon hiring/contracting and then monthly by the FDR thereafter. Parties found on these lists must be immediately removed from participating in or supporting the Select Health Medicare Advantage program.
We understand that navigating Medicare Advantage rules and regulations can be difficult, and we're here to help! We have created the following tools to help our FDRs understand and meet both the Centers for Medicare and Medicaid Services (CMS) and Select Health compliance requirements.
- Select Health FDR Compliance Guide - Outlines key compliance requirements for FDRs and recommendations for meeting those requirements.
- Select Health Code of Conduct - Accessible electronically to FDRs and their employees.
- Select Health Reporting Flyer - FDRs and their employees can call the Compliance Hotline toll-free at 800-442-4845 to report issues of suspected noncompliance or potential Fraud, Waste, or Abuse (FWA). The Select Health Reporting Flyer is a document you can post in your facilities or distribute to employees to let them know how to report Medicare program compliance concerns and/or FWA to Select Health without fear of intimidation or retaliation.
- FDRs should have their own compliance policies and procedures in place to help follow and meet CMS requirements. If an FDR does not have its own policies and procedures, it may utilize Select Health’s. FDRs may submit requests for compliance policies and procedures to email@example.com or contact its Select Health business liaison or compliance contact for assistance.
Information for Providers, Pharmacies, and Agents
If you are a participating, contracted provider or pharmacy in the Select Health Medicare network serving Medicare beneficiaries, access the Select Health Compliance/FWA information via the Select Health Provider Portal.
If you are a Select Health agent, access the Select Health Compliance/FWA information via Select Health Link.
Medicare Advantage Regulations and Guidance
- Regulations governing the MA program are found at 42 CFR Part 422 and Part 423. The Code of Federal Regulations (CFR) can be accessed at: www.gpo.gov
- CMS provides additional guidance for MA plans in the Medicare Managed Care Manual (Publication # 100-16) available through the CMS Internet-Only Manuals on www.cms.gov
- CMS provides additional guidance for Prescription Drug Plans in the Medicare Prescription Drug Benefit Manual (Publication # 100-18) available through the CMS Internet-Only Manuals on www.cms.gov
- CMS requires MA plans and their FDRs to check the OIG/GSA Exclusion lists each month to prevent inappropriate payment to providers, pharmacies, and other entities that have been excluded from participation in federal programs.
- Individuals and Entities (LEIE) includes all health care providers and suppliers that are excluded from participation in federal health care programs. The LEIE is available oig.hhs.gov
- GSA’s System for Award Management (SAM) includes health care providers on the LEIE and also includes other non-health care contractors that are excluded from federal programs. The SAM is available at www.sam.gov
- CMS makes available a Standardized General Compliance and Fraud, Waste, and Abuse (FWA) Training Module that satisfies the compliance and FWA training and education requirements. The CMS module is available at www.cms.gov