Section 1876 Cost Plan Network Adequacy Guidance and the Impact on Medicare Advantage Plans

Section 1876 Cost Plan Network Adequacy Guidance and the Impact on Medicare Advantage Plans

On June 17, 2020, Medicare Advantage Plans (Part C) received a break in Network Adequacy requirements for 2021 provider network filings. The updated rules reduce requirements for several key provider categories, add a 10 percent credit for using telehealth for vital provider types, and lower the time and distance requirements from 90 to 85 percent in Micro, Rural, and Counties with Extreme Access Considerations or CEACs.

Medicare Advantage Plans will now receive a 10 percent credit on the time and distance standards. This will assist plans in determining whether members are living in areas with access to at least one provider or facility who provides telehealth services in one of the following specialties: Allergy and Immunology, Cardiology, Dermatology, Endocrinology, Gynecology/OB/GYN, Infectious Diseases, Nephrology, Neurology, Ophthalmology, Otolaryngology, Primary Care, and Psychiatry. Telehealth has been considered an important technology by CMS and other State Medicaid programs for some time to meet network adequacy. Under the current healthcare landscape and the COVID-19 pandemic, the use of telehealth has shown to been a flexible way to provide healthcare.

County type designations and ratios were also updated from 90 to 85 percent in Micro, Rural, and Counties with Extreme Access Considerations (CEAC). Reducing the time and distance standard in Micro, Rural and CEACs will allow more health plan options in these areas and is based on the changes that states have made to their Medicaid programs to achieve this goal.  It is anticipated that this change will occur automatically when plans file their networks through the HPMS system.  

Lastly, these new rules remove outpatient dialysis from the provider types subject to network adequacy reviews.  CMS, in their final rule, noted there are several ways members receive dialysis services: in home, inpatient, and outpatient settings. The review of just one setting was too narrow in nature and this was expanded to accommodate for those additional places of service. Additionally, this change will assist plans serving members in more focused areas to achieve network adequacy. In the final rule, CMS suggested that it would allow plans to attest to providing medically necessary dialysis. CMS, however, has not outlined the process or released any specific guidelines for attestation.

With all the changes as noted, Medicare Advantage Plans will need to understand and know who is providing telehealth services within their network to take advantage of these updates. While claims and other data mining will be useful, outreaching directly to providers (what is outreaching providers) will also be necessary to ensure compliance with any additional guidelines around telehealth, HIPPA, and training needed for success. In addition, provider directories notating which providers are offering telehealth will be needed to get the most use of these new services offerings. Everything considered, the new guidelines provided by CMS are a step in the right direction and show the need of telehealth and updates to the way providers are stepping up to the plate to provide them.

 

References:

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance. Updated June 17, 2020: https://www.cms.gov/files/document/medicareadvantageandsection1876costplannetworkadequacyguidance6-17-2020.pdf 

CMS Rules for MA Plans in 2021:
https://www.govinfo.gov/content/pkg/FR-2020-06-02/pdf/2020-11342.pdf