So, what does “Unreasonable Delay” really mean in Federally Facilitated Marketplaces?

As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how to meet CMS expectations.

Plans are asking—

• What standards does CMS use that makes for a rejection?
• What do we need to do?
• What exactly is deficient?

Given the short timeline, most of these plans are asking “how can we know when we jumped high enough?”

Currently, there are no reasonable standards that CMS or plans can look to. CMS responses to these questions remain vague and unspecific as plans complain that the rejection notices give no direction on what is really wrong. Instead, CMS wants plans to respond with another narrative that explains the pattern of care, any extenuating circumstances, or even a confession of network complaints. Health plans aren’t feeling too comfortable with CMS’ responses. They are still not sure they will get a “pass” with the next and final submission. Given that multiple CMS reviewers can result in varying opinions on what is sufficient, health plans are worried about the final CMS judgments.

At the same time, CMS assumed responsibility for assuring network adequacy when they initiated these reviews for 2015. So, the focus on narrow networks has placed CMS in the cross-hairs again if network complaints re-surface.

While CMS acknowledged that there might be another window after September 4th, at this point, plans should use metrics using technology support to make their case to support the narrative. Numbers and metrics plus persistence may count.
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 >>