WellSense Health Plan is a nonprofit organization that holds contracts with the Centers for Medicare & Medicaid Services (CMS), the Massachusetts Medicaid program (MassHealth), and the New Hampshire Medicaid program (NH DHHS). In order to provide cost-effective, quality health care services and prescription drug coverage to our members enrolled in any of our government programs, WellSense may contract with external individuals and entities to support our plans and members.

  • CMS categorizes these individuals and entities as First Tier, Downstream, and Related Entities (FDRs)
  • MassHealth refers to similarly contracted entities as Material Subcontractors
  • NH DHHS refers to these contracted entities as Subcontractors

WellSense refers to these FDRs, material subcontractors and subcontractors as suppliers.

WellSense is responsible for fulfilling the terms and conditions of its contracts with state and federal regulators, as is any Supplier with which we contract. Suppliers supporting our Medicare and Medicaid plans must comply with the contractual requirements outlined in their agreements with WellSense, as well as applicable state or federal laws and regulations. WellSense has implemented a comprehensive compliance program designed to ensure compliance with applicable laws, rules and regulations; help reduce or eliminate fraud, waste, and abuse; and reinforce our commitment to compliance. WellSense’s Compliance Program addresses important topics such as standards of conduct and compliance policies and procedures; compliance structure; training; risk assessment, monitoring and auditing; reporting compliance issues; and investigation and remediation of compliance issues.

Why Compliance Matters

CMS and each of our state regulators take the protection of their consumers seriously, and they pass that responsibility to our organization when acting as a CMS contractor or plan sponsor. CMS and state regulators hold our organization directly accountable for delegating activities and performance.

How to Demonstrate Compliance Success

  • Learn and execute the delegated entity compliance elements
  • Communicate the requirements across your organization
  • Document and measure performance against regulatory and contractual standards
  • Implement monitoring for performance and requirements
  • Report any gaps or deficiencies to our organization so we can work together to remediate
  • Provide a timely response to attestations
Medicare Advantage Standards of Conduct

WellSense maintains a corporate-wide Code of Conduct that outlines the values and standards that guide our business practices and day-to-day actions. As part of our Compliance Program, we have created a Medicare Advantage Compliance Guide to assist our FDRs in fully understanding and meeting their compliance obligations under WellSense’s Compliance Program. Suppliers can use it as a “quick reference” guide to understanding our compliance program expectations and ensuring that you have internal processes to support your compliance program; if there is any inconsistency between our Medicare Advantage Compliance Guide and the terms of your agreement with WellSense, the terms of your agreement shall prevail.

Please review our Medicare Advantage Compliance Guide for First Tier, Downstream and Related Entities and share it with appropriate employees. You may choose to adopt our Standards should you not have your own. As per CMS requirements, you must distribute the Standards to employees within 90 days of hire/contracting and annually thereafter.

Useful Resources

CMS Compliance Program Policy and Guidance
Exclusion Screening

All Suppliers must review the exclusion databases listed below prior to hiring and monthly thereafter for current employees, officers & directors, board members, subcontractors, consultants and vendors, as applicable. Please note that exclusion logs that include employee name, the date each database was checked, and whether or not an exclusion was found must be made available for review, upon request by WellSense or our various regulators.

Suppliers are required to complete and submit a monthly attestation affirming exclusion screenings have taken place each month, unless otherwise agreed to by WellSense.
Medicare Advantage FDR Annual Attestation

CMS requires any organization or individual that contracts with WellSense to provide administrative or healthcare service functions on behalf of WellSense as a First Tier, Downstream and Related Entities (FDR) to comply with various CMS program requirements, including but not limited to those outlined within Chapter 42 of the Code of Federal Regulations, Parts 422 and 423, also referred to as Medicare Parts C and D. Such entities are known as First Tier, Downstream and Related Entities (FDR).

Suppliers are required to complete and submit an annual attestation affirming your organization’s compliance with the referenced Compliance Program requirement which assists WellSense in demonstrating effective communication and oversight.

Reporting Potential Compliance and/or Fraud, Waste, and Abuse (FWA) Concerns

Laws, regulations, and organizational policies can be complex. While WellSense expects its Suppliers to try to do what is right, the right thing may not always be clear. To avoid confusion and facilitate compliant behavior, all Suppliers are expected to promptly report any good faith belief of a violation of the state and/or federal laws and regulations that govern WellSense’s business. To ask a question or report a concern, you may contact one of the following:

  • Email
  • Compliance Hotline
    • 1-888-411-4959
    • Toll-free and accessible 24 hours a day, 365 days a year, with anonymous reporting available
  • Mail
    • WellSense Health Plan
      Attn: Compliance Department
      529 Main Street, Suite 500
      Charlestown, MA 02129