Definitions

First-tier entity: Any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization (MAO) or Part D plan to provide administrative services or health care services to a Medicare eligible individual under the Medicare Advantage (MA) program or Part D program. (See, 42 C.F.R. § 423.501).

Downstream entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO or a Part D plan 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: Any entity that is related to an MAO or Part D plan by common ownership or control and

1. Performs some of the MAO or Part D plan’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 MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period.

Medicaid, CHC, CCBH, or CHIP Subcontractor

Subcontractor (CHIP): Subcontractor means an individual or entity that has a contract with an MCO, prepaid inpatient health plan (PIHP), prepaid ambulatory patient health plan (PAHP), or primary care case management (PCCM) entity that relates directly or indirectly to the performance of the MCO's, PIHP's, PAHP's, or PCCM entity's obligations under its contract with the state. A network provider is not a Subcontractor by virtue of the network provider agreement with the MCO, PIHP, or PAHP. (Source: CHIP Procedures Manual, effective 3/1/2019, requires MCO to adhere to 42 C.F.R. § 438.230(c), which uses this definition.)

Subcontractor (Medicaid): An individual or entity that has a contract with a PH-MCO that relates directly or indirectly to the performance of the PH-MCO’s obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP (42 C.F.R. § 438.2).

Subcontractor (CHC): An individual or entity that has a contract with a CHC-MCO that relates directly or indirectly to the performance of the CHC-MCO’s obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP (42 C.F.R. § 438.2).

Subcontractor (Community Care Behavioral Health Organization "Community Care"): An individual or entity that has a primary contract with a Primary Contractor or its BH-MCO, that relates directly or indirectly to the performance of the Primary Contractor or BH-MCO's obligation under its contract with the department. (42 C.F.R. § 438.230(c).

Delegated and Downstream Entity (DDE)

Delegated entity: Any party, including an agent or broker, that enters into an agreement with a QHP issuer to provide administrative services or health care services to qualified individuals, qualified employers, or qualified employees and their dependents (45 CFR § 156.20).

Downstream entity: Any party, including an agent or broker, that enters into an agreement with a delegated entity or with another downstream entity for purposes of providing administrative or health care services related to the agreement between the delegated entity and the QHP issuer. The term ‘‘downstream entity’’ is intended to reach the entity that directly provides administrative services or health care services to qualified individuals, qualified employers, or qualified employees and their dependents (45 CFR § 156.20).