Reprinted from the January 18, 2018, issue of AIS Health’s Medicare Advantage News

In a new memo posted this month, CMS confirmed plans to remove provider network reviews from the Medicare Advantage application process starting with the 2019 plan year and instead begin assessing all plans’ networks on a staggered, three-year cycle. Those changes, in addition to some new clarifications in the document, could put some plans at risk for compliance actions and should have all MA organizations continuously monitoring their provider networks, two industry experts advise.

CMS in a July Paperwork Reduction Act (PRA) information collection request proposed reviewing MA provider and facility networks “at a minimum of every three years or possibly sooner if there is a network triggering event, rather than our previous process of reviewing networks at the time of application” (MAN 7/27/17, p. 1). Prior to 2016, CMS generally reviewed MAO networks at the time of application or in the case of a “triggering event” (e.g., change in ownership, network access complaints). For contract year 2017, the agency began reviewing entire networks of plans requesting service area expansions (SAEs), largely in response to a 2015 Government Accountability Office report criticizing CMS’s oversight and enforcement of network requirements for MA plans (MAN 10/1/15, p. 4).

According to a Jan. 10 memo from the Medicare Drug & Health Plan Contract Administration Group, the Office of Management and Budget on Dec. 22, 2017, approved CMS’s triennial network review. The agency will soon begin pulling a sample of active contracts — including those that have not undergone a full network review since contract initiation — for the first review cycle. CMS in July estimated that the first phase of data collection will impact approximately 304 contracts’ networks.

CMS will notify selected MAOs at least 60 days in advance of the June bid deadline that they must upload Health Service Delivery (HSD) tables to the Network Management Module (NMM) in the automated Health Plan Management System. Each time a contract undergoes an entire network review for any triggering event, the three-year anniversary date would reset.

Because network reviews are no longer a part of the application process, initial and SAE applicants will have until June to formally submit their networks to CMS, according to the memo. This means new and existing MA plans will get an additional four months to submit networks for expansions, which theoretically gives them extra time to finalize contracts. But it also puts the plans at “a little bit more risk,” suggests John Weis, president, CEO and co-founder of Quest Analytics LLC in Appleton, Wis.

“From a plan perspective, if I’m not submitting my data and I don’t understand the adequacy of my network when I’m filing the application, what happens come June when I have to then show that my network is adequate?” he asks. “I have less time to cure that vs. in the past [when] I could upload the data continuously during the application process and get that automatic feedback of where I was deficient and I could fix them at that point in time.”

Sponsors at the time of application must attest that they will have a contracted network in place that meets current MA network adequacy criteria for each county in their service area prior to marketing and enrollment efforts for the upcoming contract year, and that they will monitor and maintain a network that meets current adequacy standards. CMS added that it will conduct a complete network compliance review of initial applicants but will review only the new counties of SAE applicants for calendar year 2019.

All organizations beginning in February will have a chance to upload their networks to the NMM for an “informal review,” added CMS. The agency said it will provide “technical assistance, guidance, and consultation to organizations that want to take advantage of this opportunity,” although it will give priority to initial and SAE applicants and MAOs that have been selected for the triennial review.

** MPF May Hide Noncompliant Plans**

One noteworthy warning in the Jan. 10 memo is that initial applicants failing to meet the network adequacy requirements “may be suppressed from Medicare Plan Finder [MPF] for the upcoming Annual Election Period until the initial applicant is determined to have an adequate network in place and is prepared to provide access to services under such network in a new contract.”

“That’s a pretty profound statement to the marketplace that says, ‘Look, if you’re not adequate, we have the control because we manage the MPF and if somebody comes to and types in their ZIP code, you’re not going to come up as an available option until that deficiency has been cured,’” remarks Weis.

CMS May Take Enforcement Action

Any initial or SAE applicant that still has an inadequate network by Jan. 1, 2019, may also be subject to compliance or enforcement actions, added CMS.

“I think CMS has been very clear about the importance of network adequacy and has been very aggressive with sanctions on plans around network adequacy,” says Linda Borths, chief operating officer for Quest, which assists MA plans in building provider networks. “I think that they’ve given plans a lot of time to prepare for this with providing extra tools to be able to monitor and recommendations around monitoring, so I think they’ll be pretty serious about banning open enrollment,” she predicts.

While CMS continues to refine its monitoring of network adequacy, it has also placed increasing scrutiny on the accuracy of provider directory information supplied by MAOs with a monitoring effort launched in 2016 (MAN 4/7/16, p. 1). The agency in its first round of reviews found that 45.1% of provider directory locations in online directories were inaccurate, resulting in 31 notices of non-compliance and 21 warning letters (MAN 1/26/17, p. 1). Borths says it’s important to note that in a January 2017 memo on provider director accuracy, CMS advised that organizations take steps to ensure that, when applicable, updates to provider directories are synced with updates to HSD tables.

Quest recommends that sponsors monitor their networks on an ongoing basis — “because even if your network is adequate today, what we’ve found in the marketplace is these networks change constantly” — as well as the accuracy of provider directory data, says Weis. “I think what we can argue is the next big thing coming down the pipeline is the combination of adequacy with accuracy. [That’s] really going to be the true measure of how we believe plans will be measured in the future.”

View the full PRA package at Contact Borths and Weis via April Beane at

by Lauren Flynn Kelly