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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 2024 contract year (CY 2024) application cycle, Medicare Advantage organizations (MAOs) applying for an initial or expanded service area must demonstrate that their provider network meets the network adequacy requirements for the pending service area during the application process. This is a change from the agency’s previous approach to oversight, which required MA organizations to only attest—not demonstrate—that they meet network adequacy requirements before submitting a bid for the following contract year. 

Two New Allowances

10-percentage Point Credit

To help mitigate the challenge of building a full network one year ahead of the contract year, CMS will provide applicants a 10-percentage point credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanding service area applicants.  

However, once the contract is operational, the 10-percentage point credit will no longer apply, and MA organizations will need to meet full compliance. 

Letter of Intent

Applicants will be allowed to use Letters of Intent (LOI) in lieu of signed provider contracts 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 LOI must be signed by both the MA organization and the provider with which the MA organization intends to negotiate.  

Further, applicants must notify CMS of their use of LOIs to meet network adequacy standards and submit copies (upon request) of the LOIs in the form and manner directed by CMS. At the beginning of the contract year, the MA health plan must be in full compliance, including having signed provider and facility contracts in place of the LOIs.  

CMS will also require any MA organization that uses LOIs for the application of a new or expanding service area to participate in the triennial review to evaluate compliance with network adequacy standards. This triennial review by CMS will occur during the first year a plan is operational in its new service area. 

Inside Edition: A Review of the MA Final Rule

CMS reinstates network adequacy reviews as a condition of initial or expanding service area applications. Our own Zach Snyder breaks down the changes to give you astonishing clarity on what’s new.

CY 2024 APPLICATION OPERATIONAL PROCESSES 

For the CY 2024 MA and Part D Initial and Service Area Expansion applications, CMS will generally follow the current operational processes including: 

  • Applicants to upload their Health Service Delivery (HSD) tables into the Health Plan Management System (HPMS) Network Management Module (NMM) by the application deadline.
  • Applicants to have the opportunity to submit Exception Requests. 
  • Applicants who are also due for a Triennial Review are required to submit their pending Service Area Expansion during the application process, and their existing network service areas separately, during the triennial review in mid-June. 

CMS IS MAKING THE CHANGE TO ENSURE ACCESS TO CARE 

As we’ve seen over the years, CMS continues to be laser-focused on ensuring beneficiaries receive timely and appropriate access to health care services. The agency’s decision to reinstate network adequacy reviews as a condition of initial or service area expansion applications is another step in its quest.

“Network adequacy reviews are a critical component for confirming that access to care is available for enrollees. As such, we believe that requiring applicants to meet network adequacy standards as part of the application process will strengthen our oversight of an organization’s ability to provide an adequate network of providers to deliver care to MA enrollees.”  

“Our network evaluations ensure that we are monitoring networks and requiring organizations to provide sufficient access to providers and facilities without placing undue burden on enrollees seeking covered services. Adding network reviews back to the application process will help ensure overall bid integrity, result in improved product offerings, and protect beneficiaries.”  

DISCOVER YOUR OPPORTUNITY, NETWORK BUILD AND ROI

When you’re preparing to expand your Medicare Advantage Provider Network footprint, it’s important to understand the costs and potential ROI of adding new counties. In this video, Eliza Hoffman, VP of Regional Payers, shares how she and her team can help you understand the network build effort to expand into each desired county, the potential ROI upon achieving average enrollment, and which providers to contract with to quickly and efficiently fill specialty gaps. Schedule your Complimentary Opportunity Analysis today!

Move Faster, Build Smarter with Quest Analytics

As you begin to plan for the future of your Medicare Advantage plan, you may be wondering:

  • What are the best areas for expansion?
  • Will I stay compliant with CMS requirements?
  • How can I save time and money in my recruitment process?

Quest Enterprise Services has the answers! The Medicare Advantage Network Adequacy template allows you to evaluate your network the way CMS will—giving you peace of mind.

But that’s not all. Also included are the powerful tools: Provider Impact Analysis and Opportunity Analysis—which are like icing on the cake for streamlining your expansion efforts.

  • Provider Impact Analysis, allows you to quickly prioritize your recruitment efforts by giving you a clear picture of which providers add the most value to your network.
  • Opportunity Analysis, helps you identify the best areas for your expansion—it might even be in places you weren’t thinking.

With these tools in hand, plus the help of our dedicated team of consultants, you’ll be able to guide your team towards identifying opportunities in the market—and those providers who will make all the difference in your success.

Measure Your Network Like CMS 

Ready to evaluate your provider network the same way that regulators will evaluate it? Quest Analytics delivers the answers to your test – bringing peace of mind by showing you what regulators will see when they evaluate your network. Our Medicare Advantage and Medicare-Medicaid Network Adequacy templates will reduce your compliance testing time and cost, leaving you with more time to focus on getting better insight into your data and taking action where it matters. 

Let us help you put a plan in place to address your organization’s strategy for CMS Compliance. Schedule a Complimentary Strategy Session today. 

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