September 11, 2015

CMS Memo Points to More Regulatory Intervention in Network Adequacy, Mike Adelberg Says

A recent memo from the Centers for Medicare and Medicaid Services (CMS) is the latest of many items that suggest the agency “intends to become much more activist” when it comes to ensuring network adequacy in Medicare Advantage (MA) health plans, according to Medicare Advantage News. Under policies outlined in the memo, any MA organization’s provider-network changes must be submitted to CMS, at which point the agency will determine if the changes will have sufficient impact on plan members to trigger a special-enrollment period (SEP). Mike Adelberg, senior director at FaegreBD Consulting, said the memo “strongly suggest[s] that CMS is lowering the bar for the circumstances that might trigger a midyear provider network change SEP.”

“I take the memo as a clear signal that CMS will, at some point soon, start letting beneficiaries switch plans midyear when a health plan network loses a flagship provider group or hospital system during the plan year,” Adelberg said.

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