Certification Summary

This Certification of Compliance is for the following First-Tier, Downstream or Related ("FDR") individuals or entities:

1. Individuals or entities who have entered into direct contracts with CommunityCare HMO and/or CommunityCare Government Programs (collectively, "CommunityCare") to provide administrative or health care services in connection with Medicare Advantage/Part D ("MAPD") plans sponsored by CommunityCare. Such individuals or entities are considered "First-Tier" with respect to CommunityCare.
2. Individuals or entities with whom a First-Tier individual or entity enters into a subcontract pursuant to which the subcontractor perform services in connection with MAPD plans sponsored by CommunityCare. Such subcontracted or delegated individuals or entities are considered "Downstream" with respect to CommunityCare.
3. Any entity that is related to CommunityCare by common ownership or control and either (i) performs some of CommunityCare's management functions under contract or delegation; (ii) furnishes services to CommunityCare's MAPD plan enrollees under an oral or written agreement; or (iii) leases real property or sells materials to CommunityCare at a cost of more than $2,500 during a contract period. Such entities are considered to be "Related" to CommunityCare.

By submitting this document, the Submitter (either individually or as the authorized representative of an FDR entity) certifies that he/she (or, in the case of an FDR entity, the FDR's employees, contractors and subcontractors who perform services for CommunityCare's MAPD plans) has/have completed Medicare Advantage/Part D general compliance and Medicare fraud, waste and abuse (FWA) training.

To satisfy federal training requirements, FDRs may either: (1) complete the general compliance and FWA training located on the CMS Medicare Learning Network (MLN) website (http://www.cms.gov/MLNProducts); or (2) download and incorporate the content of the MLN training into the FDR's existing compliance training program materials.

When Must Training Be Completed

FDRs must complete training within 90 days of initial hiring (or, in the case of a subcontractor, upon initial contracting) and annually thereafter. The annual training can be completed any time from January 1 — December 31.

Attestation Statement

(If the Submitter is an individual acting as an FDR): The individual Submitter named below certifies that he/she has completed general compliance and FWA training, as required by 42 C.F.R. § 423.504(b)(4)(vi)(C). Submitter also certifies that he/she has received specialized compliance training on issues presenting compliance risks unique to his/her plan functions, both at the time of initial hire, at time of contract, when requirements change, and at least annually as a condition of continued employment or contract. Submitter agrees to keep evidence that training has been completed (e.g., Submitter's MLN certificate of completion) and make such evidence available to CommunityCare upon request.

(If the Submitter represents an FDR entity): Submitter, on behalf of the FDR, attests that all persons (including employees, contractors and subcontractors) in the FDR's organization who are involved in providing services in connection with CommunityCare's MAPD plans have completed general compliance and FWA training, as required by 42 C.F.R. § 423.504(b)(4)(vi)(C), as well as specialized compliance training on issues presenting compliance risks unique to their plan functions, both at the time of initial hire, at time of contract, when requirements change, and at least annually as a condition of continued employment or contract. Submitter agrees that the FDR will maintain training logs and make them available to CommunityCare.

Please identify the type of training the Submitter completed:

Training Program through CMS MLN

Submitter's Training Program incorporating the contents of CMS MLN Training

* Submitter Name:

* FDR Name: (for FDR entities)

* NPI Number:

* Submitter Title: (for FDR entities)

* Submitter Email:

* Submitter Phone:

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