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WELCOME TO THE GATEWAY HEALTH PLAN MEDICARE ASSURED® COMPLIANCE PAGE!
Gateway Health Plan Medicare Assured® HMO SNP is a Medicare approved
Special Needs Plan (SNP) for people with both Medicare and Medicaid.
All parties, including Gateway’s employees, governing body, first tier
entities, downstream entities, related entities, and members involved with
Gateway Health Plan Medicare Assured® must comply with all applicable
federal and state laws and regulations.
Compliance Resources
Centers for Medicare and Medicaid Services (CMS)
www.cms.hhs.gov
Federal Register
http://ecfr.gpoaccess.gov/
Medicare Advantage Program
42 CFR 422
Voluntary Medicare Prescription Drug Benefit 42 CFR 423
Office of Inspector General (OIG)
http://oig.hhs.gov/
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CMS & Compliance Definitions:
Abuse: Abuse involves actions that are inconsistent with accepted,
sound medical, business, or fiscal practices. Abuse directly or indirectly
results in unnecessary costs to the program through improper payments
Compliance: Compliance efforts are fundamentally designed to
establish a culture within an organization that promotes the prevention,
detection and resolution of instances of conduct that do not conform to federal
and state law, or to federal healthcare program requirements.
Delegated Entity: An entity with which a Medicare Health
Plan has entered into written agreement to perform certain functions required
under, or governed by, federal and/or state standards that would otherwise be
the responsibility of the Plan.
Downstream Entity: Any party that enters into an acceptable
written arrangement below the level of the arrangement between a Medicare Health
Plan (and contract applicant) and a first tier entity. These written
arrangements continue down to the level of the ultimate provider of health
and/or administrative services.
First Tier Entity: Any party that enters into a written
arrangement with a Medicare Health Plan or contract applicant to provide
administrative services or healthcare services for a Medicare eligible
individual.
Fraud: The intentional deception or misrepresentation that
an individual knows, or should know, to be false, or does not believe to be
true, and makes, knowing the deception could result in some unauthorized benefit
to himself or some other person(s).
Related Entity: Any party that is related to the Medicare
Health Plan by common ownership or control and:
1. Performs some of the Health Plan’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 Health Plan at a
cost of more than $2,500 during a contract period.
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How to Report Medicare Compliance Issues:
1) Calling: Gateway Health Plan® Hot Line (calls may be
anonymous)
(412) 255-4340 or 1-800-685-5235
2) Writing: Gateway Health Plan®
Attn: Medicare Compliance Officer
600 Grant Street, Floor 41
Pittsburgh, PA 15219
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