It’s Time to Prepare for Medicare Advantage Provider Network Submissions

Network management, directory accuracy, initial applications, service area expansions (SAEs), and the new triennial review process have exposed many Medicare Advantage (MA) plans to serious issues—from policy to process and staffing to technology. As we move into the countdown for network development, expansion, and Health Service Delivery (HSD) submission for 2020, as well as plan years 2021 and 2022, it is imperative for network strategy planning to start now in order to avoid the pitfalls plans have faced with the new regulatory guidance.

In previous years, plans submitted HSD tables along with applications. 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, allowing product teams to quickly move forward with the product development process.

With the timeline changes, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. This requires plans to implement internal deadlines for the contracting process and decide whether to file a county 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, at the same time, this has exposed the increasing importance for strong network management that blends network and product strategy, as well as firm internal timelines for network expansion.

For example, last year, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership that was budgeted for AEP became a last-minute challenge for sales and marketing, and a reset on the plan budget process. 

Additionally, as MA plans gain greater flexibility in designing and offering new types of benefits to members, blending network and product strategies becomes critical. When evaluating the impact a variety of supplemental benefits could have on sales and marketing strategy, especially when addressing the social determinates of health (SDOH) that most impact your geographic area and member population, we begin to see a vast gap in the playing field—from plans sticking to the basics with meals and non-emergent transport to plans willing to invest in innovative benefit options without knowing the exact return on investment a benefit will have on patient outcomes or financial upside/downside cost.

With these changes and supplemental benefits flexibility, we may see an upswing in strategic partnerships to improve member experience, including:

  • Post-acute providers, such as transitional assisted living and skilled nursing facilities
  • Vendors offering adaptive aids to keep patients at home longer
  • Meal or grocery delivery services
  • Resources to expand transportation services

From a provider network perspective, the move toward new partnerships will likely present a few stumbling blocks, 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 plans to start early and break down silos by having group discussions that include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments to design a holistic strategy. These new, non-traditional providers will likely be dipping toes in the same deep end of the pool; extra lead time and planning will serve you well across the board.

For non-traditional providers, we would encourage all MA plans to have:

  • Planned education sessions/town hall meetings to educate new vendors/providers and better understand their needs
  • A plan for a lengthier contracting and credentialing process
  • A plan for additional onboarding and training with the new vendors
  • Additional member education time

Moving forward, as you internalize the new contracting timeline to include standard MA providers as well as any new, non-traditional supplemental benefit providers, communication and oversight will be key. This is especially important when managing provider network contracting and credentialing data, particularly when using outside sources to assist in contracting or a credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is responsible and held accountable for the compliance of the contracting and credentialing of its provider networks. Plans submitting initial and SAE applications should work backwards from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

What Should Medicare Advantage Plans Do?

Step one in any timeline is preparing a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. Consumers (and CMS) are demanding plan choices that include quality and cost efficiency as well as supplemental benefits.

Even further, with consumer-savvy, newly aged-in Medicare beneficiaries, there is a shift in patient expectations of the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive/reward programs but will expect the same level of service. Plans need to find ways to evaluate existing provider networks and newly expanded networks to meet clinical and financial goals.

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, we’re here to help. Gorman Health Group has a long history of:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of senior consultants and network analysts to effectively and efficiently stand up a contracted provider network
  • Designing and developing network and product strategies that take into account the quality, financial, risk adjustment, and Star Ratings goals critical to 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 or bid submission 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 Elena Martin at