CMS Pub. 100-18, ch. 9, § 50.1.3

42 C.F.R. §§ 422.503(b)(4)(vi)(A), 423.504(b)(4)(vi)(A)

In order to be effective, compliance policies and procedures and Standards of

Conduct must be distributed to employees who support the sponsor’s Medicare

business. Distribution must occur within 90 days of hire, when there are updates to

the policies, and annually thereafter. Sponsors may choose their distribution

method. Some examples are furnishing hard copies at the time of hire and

electronic copies thereafter, emailing an electronic copy, or posting on the company

intranet. The sponsors should have a method to demonstrate that the Standards of

Conduct and policies and procedures were distributed to employees.

The Standards of Conduct should be written in a format that is easy to read and

comprehend. Sponsors should consider translating Standards of Conduct and

policies and procedures into other languages as necessary.

In order to communicate the sponsor’s compliance expectations for FDRs, sponsors

should ensure that Standards of Conduct and policies and procedures are

distributed to FDRs’ employees. Sponsors may make their Standards of Conduct

and policies and procedures available to their FDRs. Alternatively, the sponsor may

ensure that the FDR has comparable policies and procedures and Standards of

Conduct of their own.

The sponsors should have a method to demonstrate that Standards of Conduct and

policies and procedures were distributed to FDRs’ employees. Sponsors or the FDR

may make the policies available through methods such as a fax blast, placement on

an FDR portal, in contract materials, etc. A best practice is to include appropriate

contract provisions in the FDR contract, coupled with periodic monitoring of a

sample of FDRs based on risk assessment, including a review of the FDRs’

compliance policies and procedures and Standards of Conduct.