In the latest proposed updates (CMS-4190-P) to Medicare Advantage (MA) and Medicare Part D, CMS codified exiting network adequacy requirements and incentivized MA plans to contract with telehealth providers. In addition, the proposed rule also included a number of provisions to address drug pricing such as “[lowering] beneficiary cost sharing on some of the most expensive prescription drugs, [promoting] the use of generic drugs, and [allowing] beneficiaries to know in advance and compare their out-of-pocket payments for different prescription drugs” as noted in the press release.
On first glance, the proposal seemed to be dominated by proposed changes to Part D but I was pleased to find that CMS had an entire section dedicated to network adequacy. I could do a deep dive into several provisions of this proposal but have chosen to focus on network adequacy given the clear difference in approach CMS has taken with MA as compared to Medicaid managed care.
But, before I start comparing the two different approaches, here are a few highlights of some of the proposed network adequacy changes to MA:
- MA plans must demonstrate compliance with network adequacy requirements during a triennial evaluation
- MA plans must meet maximum time and distance standards and contract with a minimum number of providers
- Thresholds will be determined by county type
- CMS has codified five county designations: large metro, metro, micro, rural, and counties with extreme access considerations (CEAC)
- County must meet population and density parameters to be included in a specific designation
- CMS proposed giving MA plans a 10-percentage point credit for contracting with telehealth providers for specified specialty providers
- Specified specialty providers are dermatology, psychiatry, neurology, otolaryngology and cardiology
So, what exactly is different?
You may recall in November 2018, CMS proposed updates to Medicaid managed care. While I personally have been disappointed in the fact that CMS hasn’t released this final rule despite being at OMB since September 2019 (!) I’m instead going to focus on the positive changes to network adequacy in that rulemaking.
As I’ve previously noted, CMS took the somewhat controversial step to remove traditional time and distance standard requirements in that rulemaking. We at URAC were pretty supportive of this step given we believe that having a validated process in place to monitor one’s provider network and meet network adequacy requirements is way more important than meeting an arbitrary number. So, imagine the look on my face as I read that CMS was going to codify time and distance requirements for MA. Now, I will acknowledge that CMS did take the extra step to establish the corresponding thresholds at the county level which is better than using a blanket region-to-region standard. However, it’s still a little disappointing that they have chosen to continue to lend credence to a purely quantitative standard.
In addition, in the latest MA and Part D proposal, CMS declined to allow telehealth to be included as part of network adequacy calculations despite including this provision in the managed care regulation. Again, while disappointed, I can’t help but think that including telehealth might not be far off given the allowance for the 10-percentage point credit.
Guess this is another “wait and see”.
To read URAC’s comments to CMS-4190-P in full, click here.