OMB Approves New Three Year Network Adequacy Review for Medicare Advantage Plans

The Office of Management & Budget (OMB) recently approved a long standing proposal from the Centers for Medicare & Medicaid Services (CMS) to change their method of network adequacy review. The proposal has been in the works for quite some time now, and is of no surprise given that a previous review by CMS found forty-five percent of Medicare Advantage (MA) provider directories are not accurate.

Under the new methodology, CMS will no longer review MA networks during the application cycle. Additionally, CMS is changing its policy for reviews triggered after specific events, such as provider/facility terminations, change of ownership transactions, network access complaints, and organization disclosed network deficiencies. Currently, such events may only trigger a partial network review.

Instead, CMS will now conduct a full network review every three years. Should an event trigger an intermediate network review, the three-year time period would be triggered and reset for that contract. The new methodology could begin as soon as 2019, with CMS reviewing about 304 plans next year. The three-year network review would require plans that have not had a triggering event within the past three years to submit data for review. CMS plans to notify organizations at least 60 days in advance before the deadline that they are selected.

If CMS’ finds a contract deficient in its network adequacy, it could impose civil money penalties or other enforcement actions. In addition, the short sixty-day time frame means no time for mitigation of network deficiencies. Because of this, as Elena Martin, GHG’s Senior Director of Provider Strategies points out, “plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS.”

Elena Martin, our Senior Director of Provider Strategy, points out: “plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS.”



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