At this time of year, we would normally be sunsetting summer, sending the kids off to school, and stepping into the splendor of fall. As we move through the seasons of 2020, we have an odd mix of sharing our kitchen table ‘office space’ and navigating a new normal with our families and co-workers.

At the same time, CMS’ new network adequacy requirements merit taking a look at where new Medicare Advantage (MA) plans have the opportunity to plant or where existing plans have the chance for a service area expansion (SAE) that may have been unattainable in previous years. 

In previous years, network changes placed many MA plans in flux and exposed serious issues ranging from policy to process and staffing to technology. With that in mind, it’s crucial that we look at the changes with a clear lens — and with ample lead time — as we enter the contracting period for network expansion and Health Service Delivery (HSD) submission for 2020/2021 and Plan Year 2022.

As with years past, plans previously submitted their HSD tables with their applications, and, by the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network, and product teams were able to quickly move forward with the product development process. With the timeline changes, however, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. 

Plans must implement their own internal deadlines on the contracting process and decide whether to file a county that is on the edge of meeting network adequacy. The extra time and latitude offered by CMS in the network submission process resulted in additional contracting time. However, it also exposed the increasing importance for strong network management, blending network and product strategy, and setting firm internal timelines for network expansion. 

For example, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership budgeted via AEP became a last-minute challenge for sales and marketing as well as a reset on the plan budget process. As plans prepare to submit their Notice of Intent to Apply in November, the Network Management Team needs to be at the table and be able to share with the C-suite how the new flexibilities in network adequacy standards afford the opportunity to expand into areas previously out of reach. 

As MA plans gain greater flexibility to design and offer new types of benefits to service their members, there becomes a critical juncture to blend our network and product strategy. When MA plans formulate their sales and marketing strategy to determine the impact that a variety of benefits could have based on addressing the particular social determinates of health that most impact their geographic area and member population, we begin to see a vast gap in the playing field from plans staying close to the basics with meals and non-emergent transport to plans on more risk and the willingness to invest in innovative benefit options without knowing the exact return on investment the benefit will have on patient outcomes or financial upside/downside cost. 

With the changes, we may see an upswing in partnerships with post-acute providers, such as, transitional assisted living and skilled nursing facilities and vendors offering adaptive aids to keep patients in their homes longer, meal or grocery delivery services, as well as an expansion on transportation services.

From a Provider Network perspective, the move forward with new partnerships will likely present a few stumbling blocks along the way, such as how to code and pay for services, and require a ramp-up period we do not see with traditional MA providers. We encourage you to start the planning process early and break down the silos by having group discussions to include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments. The new providers are likely going to be dipping their toes in the same deep end of the pool, and extra lead time and planning will serve you well across the board.

Moving forward, as you internalize the contracting timeline to include standard MA providers as well as new non-traditional supplemental benefit providers, there can never be too much communication and oversight in managing provider network contracting and credentialing data – especially when using outside sources to assist in contracting or credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is held accountable for the compliance of contracting and credentialing its provider networks. Plans submitting initial and SAE applications should work back from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

Step one in any timeline is being prepared with a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. A network must be robust and marketable. Consumers – and CMS – are demanding plans offer choices that include quality and cost efficiency as well as supplemental benefits. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive and reward programs and will expect the same level of service. Plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals. 

Where Do We Go from Here?

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, consider this: Gorman Health Group has a long history of providing the following:

• Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of Senior Consultants, Network Analysts, and a Call Center to stand up a contracted provider network effectively and efficiently.
• Designing and developing a network strategy and product strategy that consider the quality, financial, risk adjustment, and Star Ratings goals for success within the competitive landscape of your market(s).
• Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements.
• Developing a network to support a competitive supplemental benefit program.
• Preparing plans’ HSD tables for a CMS filing as well as preparing network exceptions to include all the required elements.

Let us know how we can work together now to support your plan’s goals for the upcoming submission and plan year. Contact us today to start the conversation.