Draft_MSPP_Application_Appendix_C_Network_Adequacy.pdf

Appendix C: Network Adequacy

DRAFT MSPP Application Page 1

General Approach

OPM will assess the adequacy of your provider network in each county in each service area in which you propose to offer an MSP in accordance with 45 C.F.R. §156.230 of the Exchange final rule and state law, as applicable, using time and distance standards established by the Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage plans.

CMS designates all counties in the U.S. as one of the following types: Large Metro, Metro, Micro, Rural, and Counties with Extreme Access Considerations (CEAC). Within each county type, there are separate time and distance standards for various categories of providers and facilities. These standards and a listing of U.S. counties designated by type can be found in the CMS Medicare Advantage Health Services Delivery Criteria Reference Tables.

Since the MSPP is a new program without an enrollee base to which the time and distance standards can be applied, we will instead apply these standards to a population sample, derived from Census data, that we consider representative of prospective MSP enrollees. Please note that we will not apply the CMS standards for the minimum number of providers/facilities in each county.

As part of your application, you must provide your network directory in electronic form (format to be determined). You should submit your directory in its entirety, including all providers and facilities, not just those we have listed below. In addition, you must indicate in your network directory whether each provider is accepting new patients, and identify those that are essential community providers.

In each county, we will then analyze your provider network using the applicable time and distance standard for that county and provider/facility category. We will then calculate the percentage of the population sample that would have access within the time and distance requirements to at least one provider/facility in each category listed below. Any county with 90 percent or greater access will be considered adequate. For areas and/or provider/facility categories in which your network does not meet this standard, we may:

• conduct further analysis, considering the total number of available providers/facilities in the area, and applicable State laws or regulations concerning network adequacy, if any;

• have you explain any inadequacies or provide additional information for our consideration;

• have you revise your proposed service area(s);

• have you develop a plan and timeline for enhancing your network in certain geographic areas and/or provider categories

We may permit exceptions to the network adequacy standard when we believe it is in the interest of the MSPP to do so. If we permit exceptions, we may require you to take specific steps to monitor and respond to enrollee complaints about provider access and to enhance your network. We may, in some circumstances, also require you to provide in-network benefits for services from certain out-of-network providers.

http://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/index.html?redirect=/MedicareAdvantageApps/ http://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/index.html?redirect=/MedicareAdvantageApps/

Appendix C: Network Adequacy

DRAFT MSPP Application Page 2

Provider Categories

We will conduct our analysis for the following professional provider and facility categories:

Professional Providers

• Primary Care, including:

o Family Practice o Internal Medicine o Primary Care Physician Assistants o Primary Care Nurse Practitioners

• Allergy and Immunology

• Cardiology

• Endocrinology

• Gastroenterology

• General Surgery

• Gynecology, OB/GYN

• Oncology - Medical, Surgical

• Oncology - Radiation/Radiation Oncology

• Ophthalmology

• Orthopedic Surgery

• Pediatrics (Primary Care time and distance standard applies)

• Psychiatry

• Urology

Facilities

• Acute Inpatient Hospitals

• Critical Care Services – Intensive Care Units (ICU)

• Surgical Services (Outpatient or Ambulatory Surgical Centers)

• Diagnostic Radiology

• Physical Therapy

• Occupational Therapy

• Inpatient Psychiatric Facility Services

• Outpatient Infusion/Chemotherapy