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effective compliance program. These benefits may include: • The formulation of effective internal controls to assure compliance with Federal and State laws and regulations. • Improved collaboration, communication and cooperation between health care providers, contractors and the organization, as well as within the organization itself; • Improved communication with and satisfaction of enrollees; • The ability to more quickly and accurately react to employees operational concerns and the capability to effectively target resources to address those concerns; • A concrete demonstration to employees and the community at large of the organization’s strong commitment to honest and responsible corporate conduct; • The ability to obtain an accurate behavioral assessment of employees, business partners, and vendors; • Improved (clinical and non-clinical) quality of care and service; • Improved assessment tools that could affect many or all of the organization’s divisions or departments; • Increased likelihood of identification and prevention of unlawful and unethical conduct; • A centralized source for distributing information on health care statutes, regulations and other program directives; • An environment that encourages employees to report potential problems; • Procedures that allow the prompt, thorough investigation of possible misconduct by employees and independent contractors; • An improved relationship with entities that oversee the organizations operations; • Early detection and reporting, minimizing the loss due to false claims, and thereby reducing the organization’s exposure to civil damages and penalties, criminal sanctions, and administrative remedies such as program exclusion; and • An enhancement of the structure of the organization’s separate business units. IV. Scope of the Compliance Plan A. At a minimum, the Compliance Plan shall seek to oversee the following: • Compliance with all federal and state laws and regulations for all FHCP’s lines of business • Laws, regulations, and instructions relating to Medicare Advantage and Part D Programs • Laws, regulations, and instructions relating to QHP Issuer participations standards • Compliance with internal policies, procedures, and regulatory standards Compliance Plan 1 - 3 Revised December 12, 2018 • Business ethics • Conflicts of interest • Marketing and advertising • Anti-Dumping • Relationships with contractors, including vendors, health care providers, and government agents • Anti-kickback, reimbursement and false claims issues • Political contributions • Restricted and confidential information • Substance abuse • Data submission to government health care programs and other third-party payors B. The Compliance Plan shall not cover the following, except to the extent that these areas are regulated by law, rule, regulation or internal policy: • Bioethics • Medical ethics V. Compliance Plan Elements Listed below are the seven elements of Compliance Plans as defined in the Federal U.S. Sentencing Guidelines, discussed in the Office of Inspector General's Model Compliance Plan Guidance and expanded upon in Chapter 9 of the Medicare Prescription Drug Benefit Manual relating to part D Program to Control Fraud, Waste and Abuse (“Chapter 9”). These elements provide a blueprint for design and maintenance of an effective plan to prevent and detect violations of law. Policies and Standards An organization must have established standards, policies and procedures, to be followed by its employees, contractors and other agents that are reasonably capable of reducing the prospect of criminal conduct. Oversight Responsibility Specific individual(s) within high-level personnel of the organization must have responsibility to oversee compliance with such standards, policies and procedures. Training, Education & Communications The organization must take steps to communicate effectively its standards, policies and procedures to all employees, contractors and other agents, including, without limitation, mandating participation in training initiatives and disseminating publications that explain, in a practical manner, what is required. Compliance Plan 1 - 4 Revised December 12, 2018 Effective Lines of Communication The organization must maintain effective lines of communication between the Compliance Officer, the organization’s employees, and the organization’s contractors that include mechanisms for employees and contractors to ask questions, seek clarification, and report potential or actual noncompliance without fear of retaliation. Enforcement & Discipline The standards must be consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline that will be appropriate will be case specific. Monitoring, Auditing, and Reporting The organization must take reasonable steps to achieve compliance with its standards, including, without limitation, utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by employees, contractors and other agents, and by maintaining and publicizing a reporting system whereby employees, contractors and other agents can report potential and actual noncompliant and criminal conduct without fear of retribution. Response and Corrective Action After an offense has been detected, the organization must take all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including undertaking any necessary modifications to its compliance plan to prevent and detect future noncompliance and violations of law. Responses and corrective action, if any, shall be timely so as to minimize any potential negative effects of the offense. Fraud, Waste and Abuse Plan The organization shall maintain a comprehensive plan to prevent, detect, and correct fraud, waste and abuse. The organization should develop as part of their work-plan a strategy to monitor its internal processes and downstream and related entities involved in the administration or delivery of services. VI. Context of the Compliance Plan FHCP’s Compliance Plan is a component of a broader program called “Our Values in Action.” Our Values in Action is a program designed to define, promote and maintain core values as an integral part of our corporate culture. The Plan has these main objectives: • Affirm the personal dignity and ethical capabilities of all employees, respect the inherent good that forms the foundation of their character, and acknowledge their value to the organization and community; • Communicate to all employees the critical importance of conducting business while adhering to the highest ethical standards; Compliance Plan 1 - 5 Revised December 12, 2018 • Help all employees increase their knowledge and understanding of compliance with laws and regulations; and • Establish our commitment to ethical conduct by all employees and support for the program. VII. Overview of the Regulatory Environment A. Fraud and Abuse The 1990s saw dramatic changes in the health care environment and health care fraud has become and remains a high priority for federal and state governments and law enforcement agencies. 1. Effects of fraud and abuse in health care Everyone pays the price of these great and widespread