CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations

As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.

What does that mean for Medicare Advantage plans?

Initially, CMS will pull a sample of active contracts, including those that have not had a full network review since contract initiation, and provided the plans at least 60 days’ notice before the June deadline to submit their networks. If you are a plan that may fall into this category, you have a few short months to ensure your network meets current Health Service Delivery (HSD) table requirements. When considering all the factors that can affect your adequacy, such as changes in required number of providers or simply a change in the location of members in the CMS beneficiary file, it is imperative to begin analyzing the adequacy of your network as soon as possible. Should you fail to meet current standards, there will be limited time in which to mitigate any gaps and be prepared to present to CMS.

For those Medicare Advantage plans that are not in the initial or service area expansion (SAE) application process, CMS will provide the opportunity in February 2018 for plans to upload in the Health Plan Management System Network Management Module and participate in an informal review. However, because of the shift from an application process to an operational function, initial and SAE applicants will have until June to formally submit their networks to CMS. Another key change for SAE applicants: CMS will only review your expansion counties and not your entire network.

CMS has been moving in the direction of ensuring beneficiary protections by establishing new and stringent changes in network adequacy and directory guidance. They have been clear that organizations failing to meet network adequacy standards as well as directory standards will be subject to compliance and enforcement actions. The time to invest in your provider network management program is now.

At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but develops an comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.




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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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