Network Adequacy Test Submissions for Medicare-Medicaid Plans

In follow up to the October 2014 Health Plan Management System (HPMS) memo titled “MMP Network Adequacy Standards,” the Centers for Medicare & Medicaid Services (CMS) announced dates in which Medicare-Medicaid Plans (MMPs) and Minnesota Senior Health Options Dual Eligible Special Needs Plans (D-SNPs) can check their network against the MMP standards in the HPMS Network Management Module (NMM). These standards were developed using the same methodology that is used to develop the network standards for Medicare Advantage but were adapted to reflect the population served under the demonstrations. Specifically:

• Utilization Patterns and Minimum Number of Providers — Medicare Advantage network standards are based on analysis of service utilization patterns in fee-for-service Medicare. The new standards use the same analysis but based exclusively on utilization rates for dual eligible individuals.
• Total Beneficiaries — In Medicare Advantage, network standards are set based on current market penetration in MA. In the new standards, we will use actual or projected enrollment based on the enrollment policies for each demonstration. This affects the minimum number of providers and acute inpatient hospital beds criteria.
• Time and Distance — The Medicare Advantage standards require that 90% of beneficiaries are able to reach the minimum number required for a certain provider type within the time and distance standards established. These new network standards adjusted the time and distance for certain provider and facility types in certain counties.

To ensure your health plan’s Medicare portion of the network adequately reflects and supports the beneficiaries served by this demonstration, Gorman Health Group (GHG) can analyze your existing provider file, assist in uploading the prepared files into NMM, and provide strategic planning should any deficiencies be found. The gates in the NMM will be open on the following dates:

• March 31, 2015
• May 26, 2015
• August 4, 2015

GHG advises all MMPs to be proactive and take advantage of the pre-checks available. The annual network submission deadline is September 17, 2015, with an exception request period to follow. Let’s work together to ensure your provider network not only meets CMS standards but is working to meet the strategic initiatives of your plan.

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