CMS Shuts Down Industry Concerns Over Medicare Advantage Vetting

The CMS won’t soften its request for greater authority to ensure Medicare Advantage plans have adequate provider networks, despite insurer calls for clarity and flexibility.

The CMS wants the plans to upload their networks to a central federal database for review if they haven’t undergone an entire CMS network review in the previous three years. The White House’s Office of Management and Budget must approve the agency’s proposal.

But insurers say the proposal is vague and they’re concerned they could face financial penalties without additional guidance.

Health Care Service Corp., which oversees Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, asked the CMS to refine the proposal’s definition of “significant” network changes. If a plan makes a major network change and doesn’t tell the CMS, it could face enforcement action.

“The agency does not provide specific guidelines or criteria organizations may follow when making such determinations,” HCSC said in a comment letter posted Aug. 15 on the White House’s website. “To promote a common understanding across MA organizations of the agency’s expectations, as well as to ensure compliance with CMS’ requirements, HCSC recommends that CMS further clarify and refine the definition of ‘significant’ network changes.”

But the CMS declined to elaborate, citing the Medicare Managed Care Manual’s guidance, according to a notice posted on the White House’s website Aug. 15. The agency also said every network change would need to be assessed on a case-by-case basis.

An HCSC spokeswoman did not return a request for comment on the CMS’ decision.

The Blue Cross and Blue Shield Association, which represents 36 Blue Cross and Blue Shield plans, asked the CMS to consider phasing in the three-year network adequacy review for large Medicare Advantage organizations with many contracts.

This approach would make the new policy less burdensome by not imposing a major data submission all at once on plans operating all over the country, the association said.

But the CMS again declined the request, noting that all Medicare Advantage plans must be held to the same standards in order to maintain a level playing field.

The association declined to comment on the CMS’ response.

Medicare Advantage plans did receive some relief, as the CMS agreed to give plans 60 days notice before they have to submit their networks to the federal database. The agency initially proposed a 30-day notice.

“CMS agrees that more preparation time is appropriate,” the agency said in the notice on the White House’s site.

Currently, the CMS can only evaluate plans’ compliance with its network adequacy criteria when a so-called triggering event occurs, such as when a plan starts operating under Medicare Advantage, it expands coverage offerings to new areas, or the CMS receives a complaint that a network is inadequate.

But even in those instances, sometimes the agency can only conduct a partial network review. The CMS may review a select set of specialty types or counties rather than reviewing the entire network with all specialty types and counties.

Unless a triggering event occurs and an entire network review is prompted, a Medicare Advantage plan’s network is not formally reviewed by the CMS after it first joins the program or begins to operate in a new region. The agency is hopeful its new proposal will give more up to date insight on the adequacy of provider networks.

The White House’s OMB has up to 90 days to review the request.

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