Medicare Advantage Network Adequacy

At its discretion cms may review networks at other times for instance when a plan terminates a contract with a provider when it changes ownership or when.

Medicare advantage network adequacy. Medicare advantage network adequacy requirements d snps and state contracting options. Cms is only certain to assess a plan s network upon application for a new contract or expansion of a contract s service area. On june 17 2020 cms released updated medicare advantage and 1876 cost plan network adequacy guidance for medicare advantage ma health plans to use now for contract year 2021 network submission. Medicare advantage and section 1876 cost plan network adequacy guidance 6 17 2020 pdf hsd 2020 reference file updated 2020 06 11 xlsx revised payment information form for all medicare managed care contract applications pdf.

This week our in focus section examines new guidance issued by the centers for medicare medicaid services cms regarding medicare advantage ma plan network adequacy requirements. The centers for medicare medicaid services cms regulations at 42 c f r. Medicare advantage and section 1876 cost plan network adequacy guidance last updated. In the latest proposed updates to medicare advantage ma and medicare part d cms codified exiting network adequacy requirements and incentivized ma plans to contract with telehealth providers in addition the proposed rule also included a number of provisions to address drug pricing such as lowering beneficiary cost sharing on some of the most expensive prescription drugs promoting.

Require plans to use apples to apples comparisons of retina specialists when determining quality and cost efficiency especially given the age and multiple health conditions of their patient. Brief description of rppo and pffs network requirements. Integrated care resource center. Cms expects that organizations continuously monitor their contracted networks throughout the respective contract year to ensure compliance with the current network adequacy criteria.

Assure that retina specialists are viewed distinctly from ophthalmologists in health plans. The proposal has been in the works for quite some time now and is of no surprise given that a previous review by cms found forty five percent of medicare. Network adequacy medicare advantage criteria guidance lastupdated. January 10 2017 42 cfr 422 2 42 cfr 422 112 a 1 i and 42 cfr 422 114 a 3 ii.

Overview of network adequacy requirements for medicare advantage organizations offering coordinated care plans network based pffs plans and network based msa plans and section 1876 cost organizations. June 17 2020 1. This document summarizes a telephone discussion among states cms the national association of medicaid directors and icrc regarding medicare advantage network adequacy requirements and. Medicare advantage network adequacy.