As part of ongoing efforts to improve its oversight of Medicare Advantage provider network adequacy, CMS in July submitted an information collection request to the Office of Management and Budget that set the stage for a three-year network review cycle for all MA organizations. Now, in a draft application for 2019, those seeking to participate in the MA program for the first time or looking to expand their service area would still have to file an application but would not have to upload Health Service Delivery (HSD) tables as they have in the past. The proposed change provides plan sponsors extra time to finalize provider contracts before marketing and enrollment begins and could potentially drive service area expansions (SAEs), but comes with several caveats for plan sponsors, suggest industry experts.

“Moving HSD review out of the application and into ongoing oversight is very helpful to MAOs looking to expand,” remarks Michael Adelberg, principal with FaegreBD Consulting and a former top CMS MA official. “But by expanding network review to all MAOs in an ongoing oversight program, CMS will likely end up conducting more network oversight overall.”

Draft ’19 MA App Drops HSD Tables

CMS for decades has required the uploading of HSD tables at the time of application and in 2009 began an automated network adequacy review process that meant plans had to complete their provider contracting by the early spring in order to meet “geo-mapping” access standards for the following plan year. But in a Paperwork Reduction Act (PRA) package posted last month, a table summarizing key changes for the 2019 application states that CMS would “remove HSD submission and review from the application as this is now an operational function.” Instead, CMS said applicants would have to make the following attestations:

  • It will have a contracted network in place that meets current MA network adequacy criteria for each county in its service area prior to marketing and enrollment efforts for the upcoming contract year.

  • It will monitor and maintain a contracted network that meets current CMS MA network adequacy criteria as represented in the most recent version of the HSD Reference File.

Removing HSD tables from the application process would give plans more time to get their network contracts in place as well as cancel out a cumbersome policy implemented for plan year 2017 that had CMS reviewing entire networks of plans requesting SAEs and led to reported “service area reductions.”

While the new application process in theory makes it easier to expand, it creates an area of vulnerability for plans, suggests Danielle Moon, specialist leader in the life sciences and health care practice of Deloitte Consulting LLP and also a former CMS official. “Organizations would have to be careful because if they expanded into an area with the understanding that they were going to have that adequate network and then something fell through, they could be in a situation where they’d have to later reduce the service area,” she says. “So I think it gives them more time but they would still want to make sure that they know exactly what they need to do to meet the standards and that it’s a matter of getting the contracts in place before…marketing and enrollment.”

“Presumably, network deficiencies identified during HSD review as part of a regular oversight process would be treated similarly to audit deficiencies — with remediation during the plan year,” points out Adelberg. “This would improve the current situation where a single network deficiency in a legacy county can potentially sink a service area expansion in a far-off geography.”

The removal of HSD tables from the application process also creates uncertainty as to when CMS would begin the review of such information, but based on the information provided thus far, both Adelberg and Moon estimate it could be a year between the time a plan is approved and when CMS takes a look at its entire network. In the separate PRA information collection request posted in July, CMS proposed issuing an HSD upload request letter at least 60 days in advance of the required upload to all MAOs with contracts that have not had a network review in the past 12 months. That would be the “starting point” for those contracts, said CMS, which estimated that approximately 304 contracts’ networks would be reviewed in the first year of data collection.

Existing Service Areas Could Be Impacted

“When the HSD review is expanded across MAOs, we might find cases where an MAO has existed inside a service area for many years without evidence of access problems,” suggests Adelberg. “But the network might not meet all CMS specs. It will be interesting to see how these cases are handled.”

And while it’s unclear when HSD information will be assessed, MAOs “still have to be diligent in their efforts to make sure that their networks are adequate,” advises Moon. “And they should still as a leading practice be doing those reviews on a regular basis because when CMS decides to conduct a review [e.g., as part of the new review cycle or following a triggering event, such as a potentially significant provider contract termination], the MAO will get 60 days’ notice of CMS’ review. That means that they’ll have to go back through and make sure that they have that adequate network.” It’s not clear, however, that organizations can use that 60-day period to cure deficiencies, she points out.

Meanwhile, CMS has placed increasing scrutiny on the accuracy of provider directory information supplied by MAOs with a new monitoring effort launched in 2016. The agency in January reported that 45.1% of provider directory locations listed in online directories it reviewed last year were inaccurate and that the first phase of its monitoring effort resulted in 31 notices of non-compliance and 21 warning letters.

As a result, Moon suggests that plans stay on top of not only making sure their networks are adequate but verifying the accuracy of the information they have about their networks and employ a best practice of “using and maintaining the same source of data about their provider networks to ensure that the networks are adequate and provider directories are accurate.”

View the draft application package at