CMS Pub. 100-08, ch. 10, § 10.3.2.7

A. Background Information

Only organizations, and not individuals, are eligible to enroll as an MDPP supplier.

However, MDPP services are furnished to Medicare beneficiaries by MDPP coaches in

group settings. Though these individuals furnish MDPP services on behalf of MDPP

suppliers, only the MDPP supplier itself enrolls in Medicare. To enable CMS to better

ensure the integrity of the program and the safety of the beneficiaries it serves, MDPP

suppliers must report identifying information on coaches in the Coach Roster section of the

Form CMS-20134. If a coach is being added or changed, the updated information must be

reported via a Form CMS-20134 change request

B. Coach Eligibility and Screening

As indicated in section 10.2.6 of this chapter and as outlined in the MDPP supplier

standards, MDPP suppliers cannot include on their roster (or allow MDPP services to be

furnished by) an ineligible coach. Accordingly, an MDPP coach must not:

• Currently have Medicare billing privileges revoked and be currently subject to a

reenrollment bar

• Currently have its Medicaid billing privileges terminated for-cause or be excluded by a

state Medicaid agency

• Currently be excluded from any other federal health care program, as defined in 42 CFR

1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of

the Act.

• Currently be debarred, suspended, or otherwise excluded from participating in any other

federal procurement or non-procurement program or activity in accordance with the

Federal Acquisition Streamlining Act implementing regulations and the Department of

Health and Human Services non-procurement common rule at 45 CFR part 76.

• Have, in the previous 10 years, one of the following state or federal felony convictions:

o Crimes against persons, such as murder, rape, assault, and other similar crimes for

which the individual was convicted, as defined under 42 CFR 1001.2, had a guilty

plea or adjudicated pretrial diversion.

o Financial crimes, such as extortion, embezzlement, income tax evasion, insurance

fraud and other similar crimes for which the individual was convicted, as defined

under 42 CFR 1001.2, had a guilty plea or adjudicated pretrial diversion.

o Any felony that placed the Medicare program or its beneficiaries at immediate risk,

such as a malpractice suit that results in the individual being convicted, as defined

under 42 CFR 1001.2, had a guilty plea or adjudicated pretrial diversion of criminal

neglect or misconduct.

o Any felonies for which the individual was convicted, as defined under 42 CFR

1001.2, had a guilty plea or adjudicated pretrial diversion that would result in

mandatory exclusion under section 1128(a) of the Act.

Upon enrollment or any changes to the Coach Roster section of the Form CMS-20134 that

results in a new coach being added, the contractor shall verify that the coach is not

presently excluded from the Medicare program by the HHS Office of the Inspector General

(OIG) or through the System for Award Management (SAM) (formerly, the General

Services Administration Excluded Parties List System) and, to the extent possible, whether

or not an individual coach meets the above eligibility criteria. Should the contractor

determine that an ineligibility criterion has been met pursuant to that screening but is either

unsure of the matter or unclear as to what action should next be taken, the contractor may

contact its Provider Enrollment & Oversight Group (PEOG) Business Function Lead (BFL)

for guidance.

C. Coach Eligibility Start and End-Dates

MDPP coaches may have a high turnover rate. To document which coaches are active with

a supplier at a given time, each coach will have an eligibility start and, if applicable, an

eligibility end-date.

For each change to the Coach Roster section of the Form CMS-20134, the MDPP supplier

must indicate the date of such change. (If the date of change for an individual coach is

completely blank, the contractor must develop for this information.) Per 42 CFR §

424.205(d), an MDPP supplier must report all changes to its coach roster within 30 days of

the change.

If the contractor determines the coach to be ineligible, the coach’s eligibility start and end-date shall be documented as the same date; this effectively means that the coach was never

eligible. Two other means by which a coach may get an eligibility end-date are as follows:

• When the MDPP supplier removes that coach from its roster. Here, the eligibility

end-date would be the date the MDPP supplier indicated when it updated the

Coach Roster section to remove the coach.

• When the MDPP supplier with which the coach is associated is revoked or does not

revalidate its enrollment. Here, the coach’s eligibility end-date is the same as the

date the MDPP supplier’s billing privileges were no longer effective.

An MDPP supplier may only be paid for services furnished by eligible coaches within their

eligibility start and end-dates.

D. Consequences for Coach Ineligibility

If the contractor or CMS determines that an MDPP supplier has an ineligible coach on its

roster, the MDPP coach would be non-compliant with the MDPP supplier standards. The

supplier would thus have its enrollment denied or revoked, as appropriate under §§

424.530(a)(1) or 424.535(a)(1). Consistent with existing procedures, MDPP suppliers may

submit a corrective action plan (CAP) removing this coach from its roster within 30 days of

receiving notice of its enrollment denial or revocation, and, if compliant and as applicable,

could obtain or maintain Medicare enrollment. (See section 10.6.18 of this chapter for more

information on CAPs.) In this CAP situation, the supplier need not submit any

documentation beyond updating the Coach Roster section of the Form CMS-20134 to

remove the ineligible coach.

E. Special Revocation for Knowingly Using an Ineligible Coach

While MDPP supplier standards indicate that an MDPP supplier may not include an

ineligible coach on its roster or allow the latter to furnish MDPP services on its behalf to

Medicare beneficiaries, the MDPP supplier is not prohibited from continuing to employ or

otherwise permit the coach to volunteer for other services unrelated to MDPP. Should CMS

identify that an MDPP supplier is knowingly allowing an ineligible coach to continue

furnishing MDPP services, the MDPP supplier would be revoked under § 424.205(h)(5)

and any other revocation authority. In this context, “knowingly” means that the MDPP

supplier meets all of the following five conditions; specifically, the supplier:

• Received an enrollment denial or revocation notice for failing to meet the MDPP

standard in § 424.205(d)(3);

• Was provided notice by CMS or the contractor of the coach’s ineligibility, and the

applicable reason(s);

• Submitted a CAP to remove the coach;

• Became compliant once again and obtained or maintained its enrollment; but

• Continued to allow the ineligible coach who was removed from the Coach Roster

section of the Form CMS-20134 to provide MDPP services in violation of the CAP.