First Tier, Downstream & Related Entities

Care N’ Care Insurance Company of North Carolina, Inc. d/b/a HealthTeam Advantage is committed to conducting business with integrity and in compliance with all laws and regulations. We are focused on ensuring we remain a company that others want to do business with, now and for many years to come.  We strive to develop and maintain mutually beneficially relationships with our First Tier, Downstream, and Related Entitles (FDRs).  FDRS are defined as:

  • First Tier Entity:  Any party that enters into a written arrangement, acceptable to CMS, with an MA/PDP organization or applicant to provide health care, prescription or administrative services for a Medicare-eligible individual under MA/PDP programs (42 CFR § 422.2, 42 CFR § 423.4).  Examples of first tier entities, include but are not limited to, pharmacy benefit managers, contracted hospitals, clinics, and providers.
  • Downstream Entity:  Any party that enters into an acceptable written arrangement below the level of the arrangement between and MA and PDP organization (and contract applicant) and a First Tier Entity.  These written arrangement continue down to the level of the ultimate provider of health and/or administrative services (42 CFR §§ 422.500 (b) (3) (ii) (2).
  • Related Entity:  Any entity that is related to the Plan Sponsor by common ownership or control and 1) performs some of the Plan Sponsor’s management functions under the 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 Plan Sponsor at a cost of more than $2,500 during a contract period (42 CFR §§ 422.500; 42 CFR §§ 423.501).   An example of a related entity would be where a Plan Sponsor has an ownership interest in a pharmacy benefit management company.

FDRs must comply with the CMS Medicare Compliance Program requirements. The requirements apply to any First Tier Entity and their downstream entities.  Below are the some resources to help you in this effort.

CMS Required Training