Passing Marketplace Reasonableness — One More Chance
September 4th was final submission day for Marketplace plans but some worried health plans were asking “what ifs” about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn’t approve their network access plan. Of course, they are still asking what standards need to be met.
Rest assured, CMS says they will have another bite to justify reasonable access. However, time periods shrink. The window opens on September 23 when CMS notifies health plans about needed corrections and responses are due on September 25.
CMS is well aware that failure to get a pass has unwanted consequences for everyone. Service areas will need to be reduced with compounding changes to plan packages that necessitate more CMS re-review and approval. So, everyone wants a good justification but CMS is not backing off given the potential for political backlash. Failure is an option. Health plans worried about their last re-submission can’t count on CMS reviewer fatigue. Health plans asking these “what if ” questions need to prepare a contingency narrative by either finding and fixing any weaknesses or documenting metrics that demonstrate access. Waiting to correct over a two-day window, is not sufficient time to prepare the last chance narrative justification for reasonable access.
Resources
Gorman Health Group’s network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>
Join John Gorman, GHG’s Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>