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CMS Delays but Finalizes Changes on Network Adequacy

The ultimate rule utilizing “Contract Calendar year 2023 Policy and Technical Alterations to the Medicare Edge and Medicare Prescription Drug Reward Programs” is now out there for critique, and set for publication in the May well 9, 2022 Federal Sign up.   The remaining rule adopts the proposed modify that needs first and company spot expansion candidates to post their proposed contracted networks in the course of the software system.  The final rule delays this change from deal year 2023 to deal calendar year 2024.

In creating this change, CMS is essentially reverting to its approach prior to 2019, when it commenced permitting programs to attest to network adequacy for new contract or support space growth programs, and relied on its triennial network review system to examine compliance with community adequacy criteria for new and expanded contracts.

CMS expressed concern primarily based on 3 a long time of knowledge that the attestation-only course of action could have an effect on the integrity of the bidding process.  It particularly mentioned that a amount of programs have asked for to cut down the services space determined in their bid proposal once they recognized that they did not have a enough network for 1 or extra counties integrated in the company region.  The number identified as in search of such modifications is smaller: due to the fact 2019, 5 companies asked for to make changes to the services place of a whole of 10 designs immediately after bid submission deadlines.  On the other hand, in CMS’ see, when a prepare has to revise its bid to remove a county, it is possible that the preliminary bid submission was not entire, timely, or exact.

CMS also famous that its article-software network adequacy evaluations showed a pattern of companies continuing to have insufficient networks even immediately after their deal grew to become operational.  CMS discovered a complete of 19 plans that fell into this group.

The first situation that prompted the change in 2019 has not long gone away, which is the opportunity challenge of candidates securing a full company community nearly a calendar year in advance of the contract turning into operational.  The software is commonly submitted in February – all-around 10 months prior to the deal year that begins on January 1.  CMS been given a lot of reviews about the issue of acquiring ultimate contracts in time for the application process, specifically in underserved parts or individuals with fairly couple of companies.

CMS acknowledged the validity of strategy feedback, and did not entirely make clear why it determined to improve the software approach for all strategies, somewhat than using its authority to consider actions versus the little quantity of options that have demonstrated a trouble with community adequacy compliance – this sort of as disapproving a ask for for a new contract or company space growth for a program that seeks to adjust its support location just after bid submission, or suspending enrollment until eventually an operational strategy comes into compliance with community adequacy criteria.   As an alternative, CMS will give two varieties of relatively confined flexibility for organizations to mitigate the effects of the transform:

  1. CMS will let a 10-share issue credit rating to the percentage of beneficiaries residing within just published time and length criteria for the contracted community in the pending service location, at the time of application and for the period of the application overview.
  2. CMS will permit plans to use letters of intent (LOIs) in lieu of signed supplier contracts, at the time of application and for the duration of the application evaluation. The LOI should be signed by both the MA organization and the provider.  Applicants have to notify CMS of their use of LOIs to meet network standards.

At the starting of the agreement 12 months (that is, January 1), this overall flexibility would no lengthier utilize, and ideas would will need to meet up with network adequacy standards for the full assistance place with remaining, signed service provider and facility contracts.