Medicare & Medi-Cal Disclosures

Overview

Nivano Physicians provides comprehensive disclosures regarding Medicare and Medi-Cal programs to ensure transparency and compliance with federal and state requirements. These disclosures inform beneficiaries of their rights, coverage options, and important program information.

Legal Requirements

These disclosures are provided in compliance with:

42 CFR §411.362(b)(3)(ii)(C) – Physician ownership disclosures
Medicare Modernization Act – Creditable coverage requirements
ACA Section 6409 – Self-referral disclosure protocols
California Knox-Keene Health Care Service Plan Act
California Health and Safety Code Sections 1340-1399.8
DHCS All Plan Letters and guidance documents

Medicare Program Disclosures

Medicare Advantage Plans

Plan Participation

Nivano Physicians contracts with Medicare Advantage plans to provide healthcare services to Medicare beneficiaries. Our participation includes:

In-network provider status with contracted plans
Care coordination and case management services
Prior authorization and utilization management
Quality reporting and performance measurement
Member advocacy and appeals support

Provider Network Changes

We are required to notify Medicare beneficiaries of:

Network termination with 30 days advance notice when possible
Significant changes in provider availability
Facility relocations or service modifications
Specialty care access and referral processes

Medicare Part D Prescription Drug Coverage

Creditable Coverage Disclosure

Important Notice: If you have creditable prescription drug coverage from another source, you should maintain that coverage and may not need to enroll in Medicare Part D immediately.

Annual Disclosure Requirements

We provide annual disclosure by October 15th each year to all Medicare-eligible individuals regarding:

Whether our coverage is creditable prescription drug coverage
Options for enrollment in Medicare Part D plans
Consequences of delayed enrollment
Contact information for questions and assistance

Online Disclosure to CMS

We submit required creditable coverage information to CMS within 60 days of the beginning of each plan year and within 30 days of any material changes to coverage.

Physician Ownership and Financial Relationships

Physician-Owned Hospital Disclosures

For any physician-owned hospitals in our network, we disclose:

Ownership relationships between physicians and facilities
Financial interests that may affect referral decisions
Alternative facilities available for services
Patient choice in facility selection

Open Payments Program Compliance

We comply with the Physician Payments Sunshine Act by:

Reporting payments to physicians and teaching hospitals
Maintaining transparency in financial relationships
Providing access to Open Payments database information
Annual reporting of industry relationships

Quality and Performance Information

Star Ratings and Quality Measures

We provide information about:

Plan star ratings and quality performance
Clinical quality measures and outcomes
Member satisfaction survey results
Healthcare provider performance data

Quality Improvement Activities

Clinical guideline implementation and monitoring
Patient safety initiatives and outcomes
Chronic disease management programs
Preventive care services and screenings

Medi-Cal Program Disclosures

Managed Care Plan Information

Plan Operations

Nivano Physicians operates as a Medical Group contracting with Medi-Cal managed care plans:

Delegated services including medical management
Quality assurance and improvement programs
Member services and complaint resolution
Provider network management and credentialing

Knox-Keene vs. Non-Knox-Keene Plans

We contract with both types of plans and inform members of:

Regulatory oversight differences between plan types
Appeal rights and external review options
Consumer protection variations
Complaint processes specific to each plan type

Member Rights and Protections

California-Specific Rights

Medi-Cal members have enhanced rights under California law:

15-day medical record access requirement
Language interpretation services in threshold languages
Cultural competency standards for providers
Enhanced privacy protections under CMIA

Appeals Process Distinctions

Two-Step Medi-Cal Appeals Process:

Health Plan Appeal (60 days to file, 30 days to resolve)
State Fair Hearing (120 days to request from DHCS)

Independent Medical Review (IMR):

Available for Knox-Keene licensed plans
External physician review of medical necessity decisions
No cost to members
Binding decision on medical appropriateness

Language Access Services

Threshold Languages in California

We provide materials and interpreter services in California’s top 15 LEP languages:

Spanish, Chinese (Mandarin/Cantonese), Vietnamese, Korean, Tagalog
Russian, Arabic, Hmong, Japanese, Thai, Punjabi, Cambodian, Laotian, Hindi, Persian

SB 223 Compliance

In accordance with Senate Bill 223, we provide:

Translated vital documents in threshold languages
Qualified interpreter services at no cost
Cultural competency training for staff
Language assistance for all member interactions

SB 923 Requirements (Effective March 1, 2025)

We comply with Senate Bill 923 requirements for:

Transgender-inclusive healthcare training for providers
Provider directory updates to reflect inclusive practices
Non-discrimination policies for LGBTQ+ members
Cultural competency in transgender healthcare

Compliance and Reporting

External Oversight Agencies

Federal Agencies

Centers for Medicare & Medicaid Services (CMS)
- Website: www.cms.gov
- Phone: 1-800-MEDICARE (1-800-633-4227)
- TTY: 1-877-486-2048

California State Agencies

Department of Health Care Services (DHCS)
- Website: www.dhcs.ca.gov
- Phone: 1-916-445-4171
- Medi-Cal Ombudsman: 1-888-452-8609
Department of Managed Health Care (DMHC)
- Website: www.dmhc.ca.gov
- Help Center: 1-888-466-2219
- TTY: 1-877-688-9891

Reporting Requirements

CMS Reporting

We submit required reports to CMS including:

Quality measure data and outcomes
Encounter data for services provided
Financial and operational reports
Compliance certifications and attestations

DHCS Reporting

We provide required information to DHCS including:

Performance measures and quality indicators
Access and availability standards compliance
Member complaints and grievance data
Network adequacy and provider capacity

Financial Disclosures

Ownership and Control Information

Material Ownership Changes

We disclose any material changes in:

Ownership structure of 5% or more
Control relationships among entities
Management agreements with affiliates
Financial arrangements affecting operations

Business Relationships

We maintain transparency regarding:

Vendor contracts and service agreements
Referral relationships and financial arrangements
Joint ventures and partnership agreements
Investment interests in healthcare entities

Revenue and Financial Performance

Cost Reporting

We provide required financial reports including:

Medical loss ratios and administrative costs
Quality bonus payments and incentive distributions
Risk adjustment and supplemental payments
Financial reserves and solvency measures

Member Resources and Support

DHCS Office of Patients’ Rights

Phone: 1-888-452-8609
Email: MMCDOmbudsmanOffice@dhcs.ca.gov
Website: www.dhcs.ca.gov/
Services: Appeals assistance, complaint resolution, member advocacy

For Medi-Cal fair hearings:

Phone: 1-800-743-8525
Website: www.cdss.ca.gov
Services: Administrative hearings, appeals, and dispute resolution

Medicare Resources

1-800-MEDICARE: General Medicare information and assistance
Medicare.gov: Online tools, plan finder, and resources
State Health Insurance Assistance Program (SHIP): Free counseling
Medicare Rights Center: 1-800-333-4114

Contact Information

Nivano Physicians Member Services

Phone: (916) 407-2000 ext 82512
Hours: Monday-Friday, 8:00 AM – 5:00 PM PST
TTY: 711
Email: pr@nivanophysicians.com

Compliance and Regulatory Affairs

Phone: (916) 407-2000
Email: compliance@nivanophysicians.com
Mail: 2554 Millcreek Drive, Suite 100, Sacramento, CA 95833

Medicare and Medi-Cal Specific Questions

Medicare Specialist: (916) 407-2000 ext 82512
Medi-Cal Specialist: (916) 407-2000
Language Services: Available upon request

Document Updates and Revisions

This disclosure document is reviewed and updated:

Annually or more frequently as needed
When regulations change affecting disclosures
Upon material changes in operations or relationships
As required by CMS or DHCS guidance

Current Version: 1.0
Effective Date: August 7, 2025
Next Review Date: August 7, 2026

These disclosures ensure transparency and compliance with federal and state requirements for Medicare and Medi-Cal programs. We are committed to providing accurate, timely information to support informed healthcare decisions.