Three-Year Network Adequacy Review for Medicare Advantage Plans

If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019.

Normally this time of year we remind plans to start contracting with providers in order to meet CMS network requirements for new and service area expansion needs. This reminder still rings true. Given the lead-time it can take to negotiate contracts with providers and facilities, plans need to be proactive in the recruitment/contracting department to ensure you have a compliant network within your proposed expansion area. Moreover, while the proposed CMS changes may not require plans to submit a Health Service Delivery (HSD) table with the initial or service area expansion application, it does not negate the requirement to meet CMS standards for an adequate provider network.

The three-year network review would require plans that have not had a triggering event within the past three years to submit their HSD provider and facility files via the Network Management Module within the CMS Health Plan Management System (HPMS). Currently the triggering events are:

1. Initial Application
2. Service Area Expansion (SAE) Application
3. Initial Offering of a Provider-Specific Plan
4. Potentially Significant Provider/Facility Contract Termination
5. Change of Ownership
6. Network Access Complaints
7. Organization-Disclosed Network Deficiency

Reviewing plan network adequacy was born out of beneficiary protections and member complaints. And while there is some concern moving to a three-year cycle could impact beneficiaries negatively by lessening the upfront review, there is greater concern for beneficiaries enrolled in a plan that may not have had any sort of triggering event and have never had their provider network reviewed since they first applied. By moving the network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS.

If you are looking to expand your network footprint or want to be proactive in reviewing your current network status and building a compliant network monitoring plan, Gorman Health Group can help. Our veteran teams of consultants are available to assist with all your contracting and expansion needs as well as with the review of your current network and helping you develop a monitoring plan before CMS knocks on your door.



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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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