If you’re involved with compliance, market expansion, or provider recruitment for a Medicare Advantage Organization (MAO), listen up! The Centers for Medicare & Medicaid Services (CMS) tightened its network adequacy oversight, and it’s crucial to understand how this change will impact you and how to navigate the new requirements to ensure compliance. Let’s break it all down.
CMS Reinstates Network Adequacy Reviews as a Condition of Initial or Expanding Service Area Applications
Updated Oversight Approach
In the past, MAOs only had to attest that they met network adequacy requirements when applying for the following contract year. However, under the updated oversight approach, MAOs applying for an initial or expanded service area must now demonstrate that their proposed provider network meets the network adequacy requirements for the pending service area during the application process.
Changes to the MAO Application Process
Proving Network Adequacy: HSD Table Submission
First, MAOs must prove that their proposed provider network meets the network adequacy requirements for the number of primary care providers (PCPs) and specialists within the designated time and distance standards.
To fulfill this requirement, MAOs need to submit their provider and facility Health Service Delivery (HSD) tables to the Network Management Module (NMM) of the Health Plan Management System (HPMS). CMS will review the HSD tables to determine if the provider network meets the requirements.
Building Ahead: Timeline Adjustments
Second, the rule implies that the proposed network is adequate one year before it is live. This has a significant impact on MAOs, as it forces them to adjust their timelines for future provider networks.
Key Application Date
Applications must be submitted and received no later than February 14, 2024, at 8:00 p.m. EST.
P.S. If you prefer video, watch this YouTube Video instead.
MEDICARE ADVANTAGE APPLICATION CHANGES
Scott Westover, SVP of Network and Regulatory Strategy at Quest Analytics, explains what the new network adequacy rules mean for Medicare Advantage Organizations.
Two Allowances For Initial or Service Area Expansion Applications
Tools to Meet Network Adequacy Requirements
Building a compliant network one year ahead of the contract year is no small feat. Recognizing the time and effort required, CMS offers two allowances to help MAOs meet network adequacy requirements. Let’s explore these tools further.
Application Allowance 1: 10% Application Credit
CMS provides applicants with a 10-percentage Point Credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanded service area applicants.
It’s important to note that the Application Credit only applies during the application process. Once the contract is live, the credit will no longer apply. The MAO must meet full network adequacy requirements for the entire service area, beginning January 1 of the contract year.
Key Takeaways: Using the Application Credit
- The Application Credit only applies during the application process.
- The 10% credit will be automatically applied in HPMS and reflected on the MAO’s Automated Criteria Check report.
- The 10 percent credit is in addition to other credits such as the Telehealth or Certificate of Need (CON) credits, if applicable.
- Once the contract is live, the credit will no longer apply.
- The MAO must meet full network adequacy requirements for the entire service area, beginning January 1 of the contract year.
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Two Temporary Allowances
Applicants must be in full network adequacy compliance by January 1st of the contract year.
Application Allowance 2: Letters of Intent
MAOs can also use Letters of Intent (LOIs) to meet network adequacy requirements. Applicants are allowed to submit a Letter of Intent to contract in place of a signed provider contract at the time of application and for the duration of the application review to meet network standards in counties and specialty types as needed. The intention is to give applicants seeking to expand into a new market the opportunity to reach the threshold for network adequacy while still finalizing contract details.
Important Considerations for MAOs Using Letters of Intent
Keep two aspects in mind if you are considering using a Letter of Intent.
Conversion into Full Contract by January 1
Starting from January 1, of the go-live date, LOIs must be converted into full contracts to count towards meeting the network adequacy requirements. This means that MAOs must ensure that the LOIs are transformed into fully executed contracts before this deadline.
Participation in the Triennial Review
Additionally, CMS will require any MAO that uses a Letter of Intent for the application of a new or expanded service area to participate in the Triennial Review. This review allows CMS to evaluate the compliance of the network with published network adequacy standards. It’s important to note that the Triennial Review occurs during the first year a plan is operational in its new service area.
Key Takeaways: Using Letters of Intent
- The Letter of Intent is only for Initial or Service Area Expansion counties.
- Be sure to fully understand and leverage the Letter of Intent flexibility.
- Have a process and plan to assess your network for compliance regularly and after every mid-year termination.
- Don’t underestimate the effort and time required to convert to a full contract. Each Letter of Intent must be signed per unique NPI.
- If a Letter of Intent is incorrect, the MAO will have 10 days to correct and resubmit to CMS.
- When resubmitting, all other Letters of Intent must be included with the corrected one.
- CMS will require any MAO that uses a Letter of Intent for the application of a new or expanded service area to participate in the Triennial Network Review to evaluate compliance with network adequacy standards.
- The Triennial Network Review by CMS will occur during the first year a plan is operational in its new service area.
3 Steps to Help You Prepare for Your Medicare Advantage Application
As an MAO, you know that success in managing your provider network is all about staying ahead of the game. And when it comes to your network submission, there are a few important steps you should be taking right now. Let’s dive into what you should be doing to ensure a seamless process.
Step #1: Review and Validate the Provider Network
Before submitting your network, it’s essential to review your data with a fine-tooth comb. Pay special attention to the two new behavioral health provider specialties in your HSD tables. Make sure they’re accurately listed and that your network meets the requirements for network adequacy. This step ensures that you have the updated and complete information necessary for a successful submission.
Step #2: HSD Tables Must Match Your Provider Directory
To avoid any discrepancies or compliance issues, it’s crucial to ensure that your provider directories and HSD tables match. Take the time to compare and cross-check the data in both sources. This way, you can be confident that your provider directories accurately reflect the information listed in your HSD tables.
Step #3: Limit Provider Locations in HSD Tables
When it comes to your HSD tables, it’s important to set limits on the number of locations listed for each provider. To stay in compliance and avoid any concerns, ensure that providers in your HSD tables are limited to 5-10 locations.
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Assessing Medicare Advantage Network Adequacy and Provider Directory Accuracy
Maximizing Compliance and Success
Stay updated on the recent updates to network adequacy oversight by CMS and understand how it impacts MAOs. By ensuring compliance, meeting new requirements, and proactively addressing network adequacy, your organization can provide top-quality care to beneficiaries while also achieving goals of compliance, expanding in the market, and recruiting providers. Quest Analytics is here to assist you throughout this process, offering expert guidance and actionable insights to help you optimize your provider networks and ensure compliance. Have questions? Reach out to us today and let our experts guide you.
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