Network Adequacy Top of Mind for CMS

The Centers for Medicare & Medicaid Services (CMS) continues to reinforce its focus on health plan provider networks with several recent announcements.

The release of the new Network Management Module (NMM) within the Health Plan Management System (HPMS) is the tool CMS will utilize for monitoring network adequacy. The NMM functionality allows both CMS and organizations to evaluate health services delivery (HSD) provider and facility networks separate from the annual application process. The NMM employs the same evaluation criteria and calculations currently used by the automated network review portion of the Medicare Advantage (MA) initial and Service Area Expansion (SAE) application process. Please note organizations can access the NMM functionality to submit their network tables for an “organization-initiated” automated review. Results generated for an “organization-initiated” review will only be available to your organization and not be viewable by CMS. Our subject matter experts at GHG are able to assist plans in utilizing this new functionality as part of an overall network audit and maintenance policy plans should adopt to continually assess how their network, as its largest asset, meets the goals of the organization.

Additionally, CMS released the Draft 2017 Letter to Issuers in the Federally-facilitated Marketplace (FFM) on December 23, 2015, and is proposing new policies on network adequacy and monitoring to provide more transparency and detail to be Qualified Health Plans (QHPs) in an FFM to fulfill the requirements to provide reasonable provider access to their members. Plans have the ability to review the draft letter and provide comments back to CMS by January 17, 2016.  We have provided a link to the full draft letter, and, as with MA plans, Gorman Health Group (GHG) has the ability to manage your network adequacy reports and audit for all QHPs.

Lastly, on January 13, 2016, CMS provided training on the summary of changes to the 2017 MA applications. One of the key points addressed is the SAE application will require HSD Tables for the entire Medicare Advantage Organization (MAO) network at the contract level, not just the counties the application is proposing to expand into with the SAE request. The change comes as CMS has indicated plans should have tighter control on their existing provider networks to ensure adequacy is met over the life of the contract.

At GHG, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan. Please reach out if we can provide guidance regarding the rules and regulations for all government-sponsored health plan networks.



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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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