NEW CMS NETWORK ADEQUACY REQUIREMENTS
- Demonstrate Adequate At the Time of Application
- 10-percentage Point Application Credit
- Letter of Intent to Contract
CMS REINSTATES NETWORK ADEQUACY REVIEWS AS A CONDITION OF INITIAL OR EXPANDING SERVICE AREA APPLICATIONS
Starting with the 2024 contract year (CY 2024) application cycle, Medicare Advantage organizations (MAOs) applying for an initial or expanded service area must demonstrate that their provider network meets the network adequacy requirements for the pending service area during the application process.
This is a change from the agency’s previous approach to oversight, which required MA organizations to only attest—not demonstrate—that they meet network adequacy requirements before submitting a bid for the following contract year.
HSD Table Submission
MAOs must prove that their proposed provider network meets the network adequacy requirements for the number of primary care providers (PCPs) and specialists within the designated time and distance standards.
To do this, MAOs need to submit their provider and facility Health Service Delivery (HSD) tables in the Network Management Module (NMM) of the Health Plan Management System (HPMS). CMS will review the HSD tables to determine if the provider network meets the requirements.
Key Application Date
Applications must be submitted and received no later than February 15, 2023, at 8:00 p.m. EST.
MEDICARE ADVANTAGE APPLICATION CHANGES
Scott Westover, SVP of Network and Regulatory Strategy at Quest Analytics, explains what the new network adequacy rules mean for MAOs.
10 PERCENT APPLICATION CREDIT
To help mitigate the challenge of building a full network one year ahead of the contract year, CMS will provide applicants a 10-percentage point credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanding service area applicants.
TAKEAWAYS ABOUT USING THE APPLICATION CREDIT
- It only applies during the application process.
- The 10 percent credit will be automatically applied in HPMS and reflected on the MAO’s Automated Criteria Check report.
- The 10 percent credit is in addition to other credits such as the Telehealth or Certificate of Need (CON) credits, if applicable.
- Once the contract is live, the credit will no longer apply.
- The MAO must meet full network adequacy requirements for the entire service area, beginning January 1 of the contract year.
Pro Tip:
Use the Quest Enterprise Services Medicare Advantage 10% Credit for Application Counties to quickly assess network adequacy for your proposed counties with the new 10% application credit.
LETTERS OF INTENT TO CONTRACT
Applicants will be allowed to use Letters of Intent (LOIs) in lieu of signed provider contracts at the time of application and for the duration of the application review, to meet network standards in counties and specialty types as needed. The intention is to give applicants seeking to expand into a new market the opportunity to reach the threshold for network adequacy while still finalizing contract details.
TAKEAWAYS ABOUT USING Letters of Intent
Keep two things in mind if you are considering using LOIs:
- By January 1, 2024, any LOIs must be full contracts to count toward meeting the network adequacy requirements.
- CMS will require any MAO that uses LOIs for the application of a new or expanding service area, to participate in the Triennial Review. This will allow CMS to evaluate the compliance of the network with the published network adequacy standards. The Triennial Review will occur during the first year a plan is operational in its new service area.
DISCOVER YOUR OPPORTUNITY, NETWORK BUILD AND ROI
When you’re preparing to expand your Medicare Advantage Provider Network footprint, it’s important to understand the costs and potential ROI of adding new counties. In this video, Eliza Hoffman, VP of Regional Payers, shares how she and her team can help you understand the network build effort to expand into each desired county, the potential ROI upon achieving average enrollment, and which providers to contract with to quickly and efficiently fill specialty gaps. Schedule your Complimentary Opportunity Analysis today!
MOVE FASTER, BUILD SMARTER WITH QUEST ANALYTICS
As you begin to plan for the future of your Medicare Advantage plan, you may be wondering:
- What are the best areas for expansion?
- Will I stay compliant with CMS requirements?
- How can I save time and money in my recruitment process?
Quest Enterprise Services has the answers! The Medicare Advantage Network Adequacy template allows you to evaluate your network the way CMS will—giving you peace of mind.
But that’s not all. Also included are the powerful tools: Provider Impact Analysis and Opportunity Analysis—which are like icing on the cake for streamlining your expansion efforts.
- Provider Impact Analysis, allows you to quickly prioritize your recruitment efforts by giving you a clear picture of which providers add the most value to your network.
- Opportunity Analysis, helps you identify the best areas for your expansion—it might even be in places you weren’t thinking.
With these tools in hand, plus the help of our dedicated team of consultants, you’ll be able to guide your team towards identifying opportunities in the market—and those providers who will make all the difference in your success.
Measure Your Network Like CMS
Ready to evaluate your provider network the same way that regulators will evaluate it? Quest Analytics delivers the answers to your test – bringing peace of mind by showing you what regulators will see when they evaluate your network. Our Medicare Advantage and Medicare-Medicaid Network Adequacy templates will reduce your compliance testing time and cost, leaving you with more time to focus on getting better insight into your data and taking action where it matters.
Let us help you put a plan in place to address your organization’s strategy for CMS Compliance. Schedule a Complimentary Strategy Session today.