New CMS HSD Guidance Issued – What’s New?

December 21, 2011
|In Provider Relations, Strategy
|By GHG Advisors

In case you haven’t studied the recent CMS HSD Guidance memo, let me save you some time (and pain).  This is the first of my blogs on the new CMS changes that will impact all MA Plans filing this year for a 2013 product launch.  Here’s what caught my attention:

• County Designations Changed – This change could move a county from Major Metro to Metro; or the reverse.  These changes may have an immediate impact on your network requirements.  You may even want to revisit the counties you pulled last season and see if they now meet CMS standards.  One Plan who examined the new standards found some of their CMS “Failed” counties now “Pass”.
• Providers Dropped – CMS dropped Laboratory and Intestinal Transplant from the network requirements.  Let’s hope this trend continues next year.  I’m sure, like me, you have a couple of specialties you’d like to see dropped.
• Physician’s Assistants and Nurse Practitioners — Something is going on with CMS’ view of these providers.  In the guidance they now call contracting with these providers a “rare” occurrence and seem to narrow their use to rural areas where they can practice independently.  We’ll follow-up on this change for clarification.
• Geriatrics — CMS has clarified the specialty to those providers that have special knowledge and interest.  No mention of a board specialty requirement.
• Cardiac and Thoracic Surgeons — CMS now appears to acknowledge that these specialties are governed by a single board academy.  However both specialties continue to be required on the HSD Provider Table.  I’m hoping what CMS has separated can be reunited next year.
• Hospital Based Providers — MA Plans are now officially relieved of contracting with Radiology, Anesthesiology, Pathology and Emergency Medicine providers.  Plans must now only assure that members seeing these providers pay in-network co-pays. 

We at Gorman are staying on top of these changes in CMS Network requirements so that we can assist you in making strategic decisions for MA expansion.  Our Network development team is keeping abreast of specific market changes to maintain our edge  on our market intel and give folks who work with us the latest impact knowledge.