AMEND MA NETWORK ADEQUACY RULES BY REQUIRING A COMPLIANT NETWORK AT APPLICATION
Could we be looking at the reinstatement of network adequacy reviews as a condition of initial or service area applications? Possibly.
The rule proposes that Medicare Advantage (MA) plan applicants demonstrate they meet the network adequacy requirements for the pending service area before CMS will approve an application for a new or expanded MA plan. This would apply to new and expanded service area MA plan applicants starting with the contract year 2024 application cycle.
“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.”1
To help mitigate the challenge of building a full network one year ahead of the contract year, the rule proposes to allow a time-limited 10-percentage point credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanding service area applicants. Once the contract year starts, the 10-percentage point credit would no longer apply, and MA plans would need to meet full compliance for the network adequacy requirements.
Explore our CMS Resource Hub to learn more strategies and best practices to stay review-ready & compliant-confident.
STATE INPUT ON PROVIDER NETWORK EXCEPTIONS
CMS is looking to coordinate with State Medicaid officials on program audits. One area of collaboration is the exception approval process when a MA plan fails to meet the specific network adequacy standards. The rule proposes CMS be able to work with State Medicaid agencies when a MA plan with a Dual Eligible Special Needs Plan (D-SNP) contract submits an exception request. The thought behind this is that State Medicaid officials may be uniquely positioned to provide relevant information CMS could consider before making a determination on the exception request. CMS states,
“State Medicaid agencies may have information and insight about such other factors that might be relevant in setting a standard for an acceptable health care delivery network in a particular service area. For example, State Medicaid agencies could provide information about the number and scope of providers enrolled and screened by the State Medicaid agency, local practice patterns, geographic barriers, or transportation dynamics.”
IMPROVING EXPERIENCES FOR DUALLY ELIGIBLE INDIVIDUALS
Individuals who are eligible for both Medicare and Medicaid can face significant challenges and barriers when trying to navigate the two programs. To improve beneficiary experiences, the rule proposes to permit CMS to coordinate with a State, that chooses to require through its State Medicaid contract, that MA plans offering D-SNPs, integrate certain Medicaid and Medicare content for plan members.
For example, requiring MA plans to create an integrated Medicaid and Medicare provider and pharmacy directory for its plan members. This is based on similar requirements that currently apply to Medicare-Medicaid Plans (MMP).
CMS anticipates that there would be operational and administrative steps at the Federal and State level that would be necessary before a MA plan could implement an integrated Medicaid and Medicare provider and pharmacy directory. This would include collaboration and coordination by CMS and the State on
- Potential template materials
- Identification of potential conflicts between Federal regulatory requirements and State law
- Setting up a process for joint or coordinated review and oversight of the integrated material
SPECIAL REQUIREMENTS DURING A DISASTER OR EMERGENCY
The rule proposes that MA plans comply with “special requirements” when there is a declaration of disaster or emergency (including a public health emergency) and disruption in access to health care. The special requirements are defined in current law and include requirements for MA plans to cover services provided by non-contracted providers and to waive gatekeeper referral requirements.
The rule proposes to define disruption of access to health care as an,
“interruption or interference throughout the service area such that enrollees do not have ability to access contracted providers or contracted providers do not have the ability to provide needed services, resulting in MA [plans] failing to meet the normal prevailing patterns of community health care delivery in the service area . . .”
MA plans would have the responsibility to determine if there has been a disruption in care. MA plans would follow the special requirements for 30 days after the disruption of access to health care ends while the disaster or emergency is ongoing and for 30 days after the end of the disaster or emergency if the disruption of access to health care continues until the end of the disaster or emergency.
Please note this proposal is not final. That means it is not yet law and may change.
CMS is actively soliciting comments through March 7, 2022. We expect CMS will finalize the rule by the end of Q2 after reviewing comments.
STAY REVIEW-READY & COMPLIANT-CONFIDENT WITH QUEST ANALYTICS
Our long-standing relationship with CMS allows us to help you position your organization for success. For the first time, both issuers and regulators can measure, manage and monitor compliance in one platform. We’ve always known that you can’t look at the adequacy of the network without looking at the accuracy of the provider data – so, we married the two to make it easier for you to ensure your networks are accurate, compliant, and driving your business forward.
Along with having the ability to see what’s right, wrong and missing from your provider data, you have access to a designated Quest Analytics Consultant. Your Consultant handles the heavy lifting of data management and analysis, so you can focus on taking action and developing your strategy. With our tools and team, you can direct your attention and resources to areas that have the greatest impact on your business.
Let us help you put a plan in place to address your organization’s strategy for CMS Compliance. Schedule a Complimentary Strategy Session today.
