Tuesday, January 24, 2023
HomeHealth LawCMS Delays however Finalizes Modifications on Community Adequacy

CMS Delays however Finalizes Modifications on Community Adequacy

The ultimate rule implementing “Contract Yr 2023 Coverage and Technical Modifications to the Medicare Benefit and Medicare Prescription Drug Profit Applications” is now obtainable for assessment, and set for publication within the Might 9, 2022 Federal Register.   The ultimate rule adopts the proposed change that requires preliminary and repair space enlargement candidates to submit their proposed contracted networks through the utility course of.  The ultimate rule delays this transformation from contract yr 2023 to contract yr 2024.

In making this transformation, CMS is mainly reverting to its course of previous to 2019, when it started permitting plans to attest to community adequacy for brand new contract or service space enlargement functions, and relied on its triennial community assessment course of to guage compliance with community adequacy requirements for brand new and expanded contracts.

CMS expressed concern primarily based on three years of expertise that the attestation-only course of might have an effect on the integrity of the bidding course of.  It particularly famous that various plans have requested to cut back the service space recognized of their bid proposal as soon as they realized that they didn’t have a enough community for a number of counties included within the service space.  The quantity recognized as looking for such modifications is small: since 2019, 5 organizations requested to make modifications to the service space of a complete of 10 plans after bid submission deadlines.  Nevertheless, in CMS’ view, when a plan has to revise its bid to take away a county, it’s seemingly that the preliminary bid submission was not full, well timed, or correct.

CMS additionally famous that its post-application community adequacy critiques confirmed a sample of organizations persevering with to have insufficient networks even after their contract turned operational.  CMS discovered a complete of 19 plans that fell into this class.

The unique situation that prompted the change in 2019 has not gone away, which is the potential problem of candidates securing a full supplier community nearly a yr upfront of the contract turning into operational.  The applying is usually submitted in February – round 10 months previous to the contract yr that begins on January 1.  CMS acquired many feedback in regards to the problem of acquiring remaining contracts in time for the applying course of, particularly in underserved areas or these with comparatively few suppliers.

CMS acknowledged the validity of plan feedback, and didn’t totally clarify why it determined to vary the applying course of for all plans, relatively than utilizing its authority to take measures in opposition to the small variety of plans which have demonstrated an issue with community adequacy compliance – akin to disapproving a request for a brand new contract or service space enlargement for a plan that seeks to vary its service space after bid submission, or suspending enrollment till an operational plan comes into compliance with community adequacy requirements.   As a substitute, CMS will present two kinds of pretty restricted flexibility for organizations to mitigate the impression of the change:

  1. CMS will enable a 10-percentage level credit score in direction of the share of beneficiaries residing inside printed time and distance requirements for the contracted community within the pending service space, on the time of utility and all through the applying assessment.
  2. CMS will enable plans to make use of letters of intent (LOIs) in lieu of signed supplier contracts, on the time of utility and all through the applying assessment. The LOI have to be signed by each the MA group and the supplier.  Candidates should notify CMS of their use of LOIs to fulfill community requirements.

Firstly of the contract yr (that’s, January 1), this flexibility would not apply, and plans would wish to fulfill community adequacy requirements for your complete service space with remaining, signed supplier and facility contracts.



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