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CMS Will Use ‘Robust’ Version of NMM to Evaluate MA Network Adequacy Year-Round

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By James Gutman, Managing Editor
May 21, 2015Volume 21Issue 10

CMS’s scrutiny of Medicare Advantage plans’ provider-network adequacy is about to take a technological leap forward as the agency expects to start using at the end of July what it calls a “more robust version” of its Network Management Module (NMM) tool. This module in CMS’s Health Plan Management System (HPMS) software will allow the agency to broaden the use — to midyear and other non-event-driven times — of its ability to “map” the provider-network locations supplied by plans and compare those with where their beneficiaries reside. It will help the agency determine on a year-round basis whether the plan sponsors are meeting CMS’s access standards for MA beneficiaries, explains Gregory Buglio, a health insurance specialist in the agency’s Medicare Drug Benefit and C & D Data Group.

Speaking at a session of CMS’s annual spring MA and Part D conference/webinar May 6, Buglio said the new module is designed to serve eventually as a “one-stop shop” for network submissions by the plan sponsors. The initial use, however, he noted, will be in a pilot program beginning in late summer or early fall that won’t yield formal scoring or be used in determining MA plans’ audit results. This first use won’t include retail pharmacies in the NMM access reviews, but both agency officials and observers indicate that is coming too, perhaps next year.

Initial limitations notwithstanding, the new use of the NMM — and what observers say is likely formal use of the tool starting in 2016 — probably will ratchet up the pressure on MA plans to make sure their members have convenient access to providers, particularly specialists. CMS’s rules require that MA insurers have network specialists within certain numbers of miles of where their members reside, although they don’t have to be in the same counties. The software takes into account “natural barriers” relating to how members actually travel to see these providers, Buglio added.

Technology Will Aid Network Scrutiny

His comments and those made earlier in the conference by Heather Kilbourne, an attorney who is a health insurance specialist in CMS’s Medicare Drug & Health Plan Contract Administration Group, made clear that MA provider access has become a major issue for the agency. This may be at least partially an outgrowth of moves in the past two years by several MA insurers — most notably MA market leader UnitedHealth Group — to shrink the size of their networks to focus on just the providers likely to produce the best clinical and financial outcomes.

Those moves have created a substantial backlash, and CMS is addressing the situation in multiple ways. As Kilbourne noted, the final 2016 MA rate notice and Call Letter (MAN 4/9/15, p. 1) included a requirement for plans to update their provider directories “in real time” and to both ascertain and communicate whether their network providers are accepting new patients. This means, she said at the session, that MA sponsors need to have regular “communications” with these providers, require the providers to notify the insurers promptly about “availability changes” and highlight the practices that are “closed” to new patients in their provider directories. Only providers that are accepting new patients should count when MA plans assess their network adequacy, CMS officials added at the conference, although this is not the current requirement.

With these policy goals in mind, CMS clearly is looking increasingly to technology to help determine MA organization (MAO) compliance and sees an enhanced version of the already-existing NMM as a logical focal point. The initial concept is that MA sponsors will submit a random sample from the Health Services Delivery Provider and Facility Tables for automated evaluation against CMS’s HSD criteria, something that now is done only for initial and service-area-expansion MA applicants.

Under the pilot outlined by Buglio, this will be done for the entire non-employer MA contract service area and throughout the year. In the pilot phase, according to Buglio, the MAO-initiated submissions “will not be viewable or evaluated by CMS” (except for technical-assistance purposes) and instead are designed as self-evaluation practice for the plan sponsors. That is in contrast to what will happen when CMS itself starts an NMM submission.

No Exceptions Process for Self-Reviews

When the MAOs themselves are initiating the reviews by NMM, he added, there will not be an “exceptions process” under which the insurers can be excused from having to meet the requirements if there are good reasons they cannot do so.

“CMS is taking a big step by letting MA plans come in any time to check their networks, but it is probably not logistically possible to review exception requests — a much more manual process — throughout the year,” Michael Adelberg, senior director at FaegreBD Consulting and a former top MA plan regulator at CMS, tells MAN.

The changes outlined in the CMS conference presentations fit with ongoing moves by the agency to use more automation in its plan-performance auditing processes, says Shelley Mueller, director, government programs practice at consulting firm HTMS. In this case, she tells MAN, the use of the NMM means MAOs wouldn’t have to send provider contracts to enable CMS to do basic analysis of provider adequacy, although the agency still might want to look at those contracts during its actual audits.

“CMS wants to be sure that when you say [to plan members] your providers are in network, they really are,” she asserts.

Adelberg agrees, adding that “the tool will let CMS measure provider networks 365 days a year. MA plans will have to stay focused on keeping their networks as strong as they were when first approved.”

The goal, said Buglio in a response at the general question session at the end of the May 6 CMS conference, “is to have a one-stop shop via the network management module.” But he also cautioned that the agency has not yet prepared guidance about the NMM, and indicated that more details may be forthcoming at CMS’s audit compliance conference scheduled for June 16.

Other observers queried by MAN say it is helpful to look at political factors to understand why CMS is moving in this direction. There has been “a lot of pushback” from consumer advocates to the plan sponsors’ recent narrow-network moves, says one source, who asked not to be identified, and the NMM gives the agency the ability to respond to complaints about networks without expending more resources than it has available for midyear checks. So when CMS gets a midyear complaint in the future about an MA plan’s network, it will be able to ask the insurer involved for provider-network evaluation through the NMM, and can impose sanctions if the access as determined by the NMM is inadequate.

The agency thus could start non-pilot use of the NMM for MA in 2016 — perhaps via a rule proposed and adopted next year — giving the Obama administration a “legacy” accomplishment in the waning days of its existence without the need of getting it through Congress, according to the observer. Unlike for the exchanges developed under the Affordable Care Act, the source adds, in MA there is no question that it is CMS and not a state that has network-adequacy regulatory authority.

The planned use would get CMS out of difficulties it has had in the past in evaluating network access in MA. The old way of doing this involved the insurers supplying big binders with details of their provider networks and CMS using road atlases to determine whether the networks are adequate. That led to non-uniform application of network adequacy by the CMS regional offices.

The new system would get around this problem and may be more feasible for enforcement in MA than it is for the new CMS-backed demonstration for Medicare-Medicaid dual eligibles since the MA plans generally are operating profitably while most duals plans aren’t at this stage.

© 2015 by Atlantic Information Services, Inc. All Rights Reserved.

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