First-Tier, Downstream and Related Entities (FDRs)
CMS Compliance Program Actionable Requirements*

Kaiser Foundation Health Plan, Inc. regions have contracts with the Centers for Medicare and Medicaid Services (CMS) to administer Part C and Part D benefits to Medicare members. Kaiser Foundation Health Plan, Inc. may delegate some of these responsibilities – providing core health plan functions or health care services – to contracted external vendors or providers.

Vendors contracted to provide a core health plan function are designated as “Administrative FDRs” and providers of health care services to our Medicare Advantage and/or Cost plan members are designated as “Provider FDRs”.

Kaiser Foundation Health Plan, Inc. maintains ultimate responsibility for ensuring its FDRs meet the requirements of the Medicare program and fulfill the delegated functions. This includes CMS compliance requirements. While the requirements are fully outlined in the contracts, ‘actionable’ requirements are listed below.

Requirements for Administrative FDRs

General Compliance Training
Kaiser Foundation Health Plan, Inc. is required by CMS to ensure its Administrative FDRs take general compliance training at least annually.  To meet this requirement, Kaiser Foundation Health Plan, Inc. has created the Vendor Code of Conduct to communicate the minimum standards by which all vendors and their employees are expected to conduct themselves when providing goods and services to Kaiser Permanente. Get Document

Fraud, Waste, and Abuse (FWA) Training
CMS also requires that FWA training be completed annually by employees involved in the administration or delivery of Medicare Parts C and D benefits.  

• Newly contracted vendors (Administrative FDRs) must ensure their employees receive training within 90 days of the contract effective date, and annually thereafter.
• New employees to vendors must receive training within 90 days of hire, and annually thereafter.
• Vendors who subcontract with entities to administer Part C and/or Part D benefits on behalf of the vendor are referred to as “downstream entities”.  These “downstream entities” (subcontractors) must also complete FWA training within 90 days of contracting with the vendor, and annually thereafter.  Vendors must ensure their subcontractors meet CMS training requirements.
• Vendors and subcontractors enrolled in Medicare Parts A or B or accredited as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are deemed to have met the FWA training requirement. Most Administrative FDRs are not deemed.

 

Kaiser Foundation Health Plan, Inc. recommends the CMS-created standardized FWA training module, which is available through the CMS Medicare Learning Network (MLN) at http://www.cms.gov/MLNProducts.   

Screening for Excluded Individuals
Kaiser Foundation Health Plan, Inc. may not use federal funds to pay for services, equipment, or drugs prescribed or provided by a vendor excluded by the Department of Health and Human Services, Office of Inspector General, and the U.S. General Services Administration. Vendors must screen their employees and subcontractors prior to employment or contracting, and monthly thereafter. Vendors can find more information and links to the exclusion databases at the following websites:  https://oig.hhs.gov/exclusions/index.asp
https://www.epls.gov/

Annual Attestation
Administrative FDRs (vendors) will be required to attest annually in writing to the following: Get document.

• The Vendor Code of Conduct has been made available to its employees.
• FWA training was completed by the appropriate employees or the vendor is deemed to have met the FWA training requirement (records of training attendance, course materials, or documentation to establish FDR is deemed may be requested).
• No excluded persons or entities provided services under the contract with Kaiser Foundation Health Plan, Inc.

Signed attestations (scanned copy of wet signature or electronic signature acceptable) following the completion of a contract year should be emailed to FDR-CMS@kp.org.

Questions related to FDR training requirements can be sent to FDR-CMS@kp.org.

*Reference:  Compliance Program Guidelines, Prescription Drug Benefit Manual, Chapter 9 / Medicare Managed Care Manual, Chapter 21