Compliance Matters
Amwins complies with The Centers for Medicare and Medicaid Services (CMS) and federal and state regulators. CMS and state regulators hold our organization directly accountable for delegate activities and performance in accordance with Chapters 9, 11 & 21 (42 C.F.R. §§422.503(b)(4)(vi) and 423.504(b)(4)(vi)) and Department of Health & Human Services, Office of Inspector General.
Amwins is committed to the ethical and legal conduct of all Amwins AGBL business operations. It is a vital component in the development, implementation, maintenance, and updating of an effective Compliance Program that meets all the federal, state, and contractual requirements. All employees, temporary employees, interns, volumeters, governing bodies, First Tier, Downstream and Related Entities (FDRs) are required to make a commitment to adhere to Amwins AGBL Compliance Program.
The Compliance program includes the following core requirements:
1. Written Policies, Procedures and Standards of Conduct
a. Promote and enforce its Standards of Conduct
2. Compliance Officer, Compliance Committee and High-Level Oversight (Board)
a. Promote and enforce its compliance program
3. Effective Training and Education
a. Effectively train and educate its governing body members, employees, and FDRs
4. Effective Lines of Communication
a. Effectively establish lines of communication within itself and between itself and its FDRs
5. Well Publicized Disciplinary Standards
a. Oversee FDR compliance with Medicare Part D requirements
6. Effective System for Routine Monitoring and Identification of Compliance Risks
a. Establish and implement an effective system for routine auditing and monitoring
7. Procedures and System for Prompt Response to Compliance Issues
a. Identify and promptly respond to risks and findings.
All employees shall not have the authority to act contrary to any provision of the Compliance Program or to condone any such violation by others. Any employee with knowledge of suspected violations of law or violations of provisions of the Compliance Program is required to promptly report such violation, as directed in the Code of Conduct and the Compliance Program, using any of the following reporting method via Amwins Hotline
FDR’s
Amwins refers to the Medicare Prescription Drug Plans (PDPs) and EGWP Employer Group Waiver Plan we offer as “Medicare plans.” We partner with external individuals when it provides the most a cost-effective way of providing the administrative and health care services that support these plans and are required under our contracts with the Centers for Medicare & Medicaid Services (CMS). CMS refers to these entities as First Tier, Downstream and Related Entities (FDRs).
CMS defines FDRs as listed below:
First Tier Entity- is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or PDP sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program.
Downstream Entity- is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a PDP sponsor 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- means any entity that is related to a Medicare Advantage Organization or PDP sponsor by common ownership or control and:
1. Performs some of the Medicare Advantage Organization or PDP sponsor’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 Medicare Advantage Organization or PDP Sponsor at a cost of more than $2,500 during a contract period.
