On December 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule impacting Medicare Advantage (MA) Organizations for Contract Year 2026. This proposal introduces pivotal provisions addressing network adequacy and provider directories. Below, we explore the key changes, including amended network adequacy exception request rationales, integration of provider directory data into the Medicare Plan Finder, the identification of community-based and in-home service providers, and codifying the definition of “county.”
Limiting Network Adequacy Exception Request Rationales
Elimination of Contracting Rationale
CMS proposes amending the existing network adequacy exception request rationale framework. One of the most notable changes is CMS’s intention to eliminate the justification that a “provider does not contract with any organization or contracts exclusively with another organization.” This modification seeks to address a notable issue where MA organizations could circumvent network adequacy criteria for a given specialty/county.
Additionally, by removing this rationale, CMS believes it will provide greater incentives for MA organizations to establish contracts with providers that are located within the established time and distance standards.
Removal of "Other" Category and Rationales
Further refining the rationale framework, CMS proposes removing the “other” category alongside the rationale that a “provider has the potential to cause beneficiary harm.” These considerations are already inherently part of CMS’s broader exception evaluation process.
In addition, CMS plans to incorporate the rationale “provider is not properly credentialed” under the existing category, “provider does not provide services for the specialty type listed in the Provider Supply file.”
Amended Valid Rationales for Network Adequacy Exception Request Rationales
Under the revised policy, the network adequacy exception rationales would include the following:
- Providers who are no longer practicing due to retirement, death, or other reasons.
- Providers who do not offer services at the facility or office address listed in the Provider Supply file.
- Providers who do not perform services under the specialty listed in the Provider Supply file.
- Providers who have opted out of Medicare.
- Providers who are sanctioned or listed on the CMS preclusion list or the List of Excluded Individuals and Entities.
- Providers who have reached capacity and are not accepting new patients.
💡 Curious to learn more about network adequacy exception requests? Read our blog post here.
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Integration of Provider Directory Data into Medicare Plan Finder
In a bid to enhance consumer transparency and informed choice, CMS is proposing to require MA provider directory data to be submitted for use to populate the Medicare Plan Finder. The Medicare Plan Finder is a resource that provides current and prospective beneficiaries information to compare and shop MA plans, including plan benefits, premiums, deductibles, and Star ratings. However, one critical component has been missing: provider network data. Without this information on the Medicare Plan Finder, beneficiaries must go between the Medicare Plan Finder and individual MA plan websites to determine whether their preferred healthcare providers are in-network.
Data Submission and Attestations
To address this gap, CMS proposes changes to make MA provider directories accessible through the Medicare Plan Finder for the 2026 Annual Enrollment Period (AEP). This provision requires MA organizations to submit their plan provider directory data to CMS/the Department of Health and Human Services (HHS). The data submission would be in a format, manner, and timeframe specified by CMS/HHS and integrated into the Medicare Plan Finder.
Additionally, CMS proposes a requirement for timely updates of provider information. MA organizations would be mandated to update the directory data submitted to CMS within 30 days of receiving change notifications from providers. This proposal aligns with the current standard for updating provider directory data.
To further support the reliability of information, CMS suggests that MA organizations must attest to the accuracy and consistency of the data submitted under the new requirements. This attestation process would ensure that the submitted data aligns with previous network data submitted to comply with CMS’s MA network adequacy requirements.
Operational Guidance and Further Steps
Should the proposed rule be finalized, CMS will provide a guide on the data submission process, including how to handle attestations. Online testing of the directory data is planned to begin in the summer of 2025, with full implementation by October 1, 2026. Therefore, CMS proposes July 1, 2025, as the applicability date for this requirement.
Promoting Transparency for In-Home Services and Community-Based Organizations
CMS acknowledges that some entities providing covered benefits, such as community-based organizations (CBOs) and in-home supplemental benefit providers, are not consistently included in MA provider directories. To address this, CMS proposes several changes to enhance transparency:
- Defining Key Entities: CMS proposes codifying definitions for CBOs, in-home or at-home supplemental benefit providers, and direct furnishing entities to ensure clarity and consistency.
- Directory Identification Requirements: MA plans would be required to clearly identify CBOs and in-home providers in their directories. This includes specifying providers offering hybrid services (in-home or at-home as well as in-office services).
- Subset or Separate Listings: Plans must organize this information in an easily accessible format, either as a subset within the existing provider directory or as a separate list for in-home and hybrid providers.
- Inclusion of Direct Furnishing Entities: CMS would mandate the inclusion of all direct furnishing entities in provider directories, clarifying that these entities must meet the same standards as other providers listed.
Defining "County" for Network Adequacy
Network adequacy is critical to ensuring that MA current and prospective beneficiaries have sufficient access to healthcare services. CMS evaluates network adequacy at the county level, which includes not only traditional counties but also areas deemed county-equivalents. These county-equivalents can be boroughs, certain designated cities, parishes, municipalities, and the District of Columbia. CMS proposes codifying its longstanding policy of treating county-equivalents the same as counties for network adequacy purposes by defining “county” in the statute.
Specific Regulatory Changes
- CMS proposes to create a new section in the regulations to define “county” as “the primary political and administrative division of most States and includes functionally equivalent divisions called ‘county equivalents’ as recognized by the United States Census Bureau (for economic census purposes).”
- Additionally, CMS proposes to modify the definition of the service area to incorporate the new definition of “county.”
Request for Feedback
CMS is seeking public comments on the proposed rule. Feedback from stakeholders will be crucial in refining and finalizing these provisions to ensure they are both effective and manageable. Public comments on the proposed rule are due by 5 p.m. ET on January 27, 2025. You can submit electronic comments here.
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