Author: Kate Deiters

CMS Changes Network Adequacy Application Process for Medicare Advantage

Medicare Advantage The Centers for Medicare and Medicaid Services (CMS) is tightening network adequacy oversight again—this time for Medicare Advantage organizations. If you're involved with compliance, market expansion or provider recruitment, we’ve broken down how the change impacts you.  CMS Reinstates Network Adequacy Reviews as a Condition of Initial or Expanding Service Area Applications  Starting with the... Read more »

What You Need to Know About New QHP Certification

On April 28, 2022, the Department of Health and Human Services (HHS) released the Notice of Benefit and Payment Parameters (NBPP) for 2023 Final Rule. In addition, the Centers for Medicare & Medicaid Services (CMS) issued the 2023 Final Letter to Issuers in the Federally-facilitated Exchanges (also known as the 2023 Final Letter). The NBPP... Read more »

Federal Medicaid Network Adequacy Standards

Federal law requires CMS to review and approve State contracts with Medicaid Managed Care Plans (MCPs), which include Managed Care Organizations (MCOs).1 The federal requirements act as a “floor,” but states are permitted to set more stringent requirements if they wish. In 2020, CMS changed the federal floor network adequacy requirements for State MCO contracts.2... Read more »

No Surprises Act Provider Directory Enforcement Guidance for Regulators

Enforcement of the No Surprises Act, Section 116, involves both federal and state regulators. As we work with many of the parties involved, here is an analysis of the various enforcement guidelines and a proposed strategy for all regulators to consider.  Section 116 of the No Surprises Act (NSA) requires health plans to establish a... Read more »

QHP Certification and New Network Adequacy Review Timeline

Updated Calendar for PY 2023 QHP Data Submission and Certification This calendar has been updated to reflect the new dates listed in the March Bulletin1 Love a good timeline? We do too! Whether you've been following the latest news about the new network adequacy requirements or you're a busy professional who doesn't want to miss a deadline, we've got you covered. Our snazzy timeline highlights... Read more »

Consideration for Health Equity Measures in Network Adequacy Standards

One way to advance health equity standards through the QHP certification process is to incorporate health equity-based network adequacy standards into the network adequacy review process.  The Affordable Care Act (ACA) directed the Centers for Medicare & Medicaid Services (CMS) to establish rules to require that Exchange health plans ensure a sufficient choice of providers.1... Read more »