Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and
business strategies about Medicare Advantage plans, product design, marketing,
enrollment, market expansions, CMS audits, and countless federal initiatives in
MA and Medicaid managed care.
By Lauren
Flynn Kelly, Managing Editor
September 15, 2016 Volume 22 Issue 18
CMS this year made several major network review
changes that have reportedly caused headaches for some Medicare Advantage
organizations (MAOs) requesting service area expansions (SAEs) for contract
year 2017 (MAN 8/4/16, p. 1). During a session of the CMS Medicare
Advantage and Part D fall conference on Sept. 8, officials from the Medicare
Drug & Health Plan Contract Administration Group (MCAG) emphasized the
rarity of network exceptions and shared a slew of common findings from its new
streamlined review process that may prove useful for MAOs submitting SAEs and
partial county requests for 2018 and beyond.
Prior to this year, CMS reviewed MAO networks
only during the initial application and when there was a beneficiary complaint,
but for contract year 2017, CMS began reviewing entire networks of plans
requesting SAEs in an effort to provide greater oversight of MA provider
networks. Stacy Davis, an analyst with the MCAG Division of Medicare Advantage
Operations, confirmed that “curative actions” for plans whose “active/existing”
counties did not meet Health Services Management and Delivery (HSD) table
criteria included removing an active county. This can be done through a
“service area reduction” module via the automated Health Plan Management System
(HPMS). Davis did not disclose how many plans have had to remove existing
counties.
Also new for 2017, CMS created a centralized
team to review network exception requests and partial county justifications,
whereas this process historically had been handled across 10 regional offices.
Davis explained that this was done in part to “increase the consistency in the
decisions we were making in the application as it related to network review.”
But while CMS recognizes that “continuously evolving patterns of
care” in certain service areas may require exceptions to network adequacy
criteria, those “exceptions should be rare and must be warranted,” emphasized
Theresa Wachter, an analyst with the Division of Policy, Analysis &
Planning (DPAP) within MCAG who also spoke at the session.
For example, if a plan were to request an exception on the basis
that it’s attempted to contract with a provider, but the contract negotiations
have not concluded, that is not likely to be accepted, said Davis. To CMS, that
rationale is like saying, “There is a provider there within your criteria. We
just haven’t contracted with them yet,” she explained. Therefore, applicants
should not submit exception requests as “placeholders” while contracting is
still in progress, Davis advised.
Other unacceptable exception requests occur when applicants do not
appear to fully understand the HSD instructions, suggested Wachter. For
example, applicants may need to contract with providers outside of their plan
service area, such as those in adjacent counties or even in neighboring states.
But CMS has found that some applicants have failed to do this when it appeared
to be necessary in order to meet adequacy criteria, she observed. So if a
doctor is within CMS time and distance criteria for County A in one state but
is located in County B in a neighboring state, the applicant should list that
provider on its HSD table to provide access for enrollees in County A, even if
the provider’s office location is not within the service area, clarified
Wachter.
Davis added that CMS often sees exception requests being submitted
when no attempt is being made to contract with another provider in order to
provide access to beneficiaries. “We still expect applicants to meet network
adequacy criteria in that 90% of beneficiaries are being covered through a
contract network,” she stated. “If because supply isn’t there [and] you have to
go outside the network criteria to do it, then that’s what we expect you to do
and that’s what you explain with your exception request.”
CMS Streamlines Partial County Reviews
CMS this year also made some adjustments to the templates for
submitting partial county justifications. But CMS continues to expect that MA
plans serve entire counties as opposed to selecting certain ZIP codes in the
county and excluding the remainder, “except for extraordinary circumstances,”
asserted Marty Abeln, another analyst with DPAP. He indicated that partial county
requests are most likely to be granted in areas that are “very sparsely
populated” and have very few providers, such as counties that contain a large
non-residential area of national park space. To the extent that there are
available providers in a service area, CMS’s expectation is that plans serve
the entire county, he added.
When submitting partial county justifications, applicants must
provide conclusive evidence showing that their request presents no
discrimination, stressed Wachter. Therefore, if an applicant provides
information to illustrate the demographics for an entire county, but offers no
evidence showing that the health care costs and racial/demographic makeup of
the population in the excluded parts of the county are comparable to the proposed
partial county, that is not an acceptable rationale.
Similar to exception requests, when reviewing partial county
justifications, CMS compares the service area to that of other MAOs as part of
its review. So if one MAO is operating in an area as a full county and another
MAO is proposing to serve the same area as a partial county, “then that may
indicate that the partial county is discriminatory and that is not warranted,”
clarified Davis.
Moreover, the inability to establish economically viable contracts
is not a valid rationale for requesting a partial county, emphasized the
speakers, referring to a policy clarification that was made in a January 2016
HPMS memo. “This is because CMS does not get in the business of contract
negotiations between an entity and a provider. If a provider won’t accept your
rates, we’re not going to grant you the partial county,” stated Davis. CMS is
also unlikely to grant partial county justifications to plans that request to
serve a ZIP code that exists in two counties but the plan wants to serve it in
only one, she added.
When asked by MAN how many partial county
requests have been filed for CY 2017 and how many were approved, the panelists
responded that they do not yet have that data.
The good news for plans submitting SAEs and partial county
justifications is that they may not be subject to a two-year ban on introducing
a new contract if they are unable to resolve any inadequacies identified by CMS
and end up not renewing their contract as a result. Current regulations permit
CMS to consider exceptions to the two-year contracting ban under certain
circumstances. As part of a recent policy change, applicants can use a new
template to request a waiver of the two-year ban and CMS will assess whether
their withdrawal was “in the best interest of beneficiaries,” added Abeln.
View a replay of the Sept. 8 conference at www.cms.gov/live.
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