CMS has implemented significant regulatory changes to network adequacy standards that require Medicare Advantage (MA) plans to quickly adapt to ensure compliance. Read on for an overview of the necessary steps plans must take to meet these new requirements.

Convert Letters of Intent. Health plans that submitted Letters of Intent (LOIs) to fulfill network adequacy requirements for initial or service-area expansion applications in 2024 for PY 2025 must convert all LOIs to CMS-compliant contracts. Plans also must complete credentialing requirements prior to January 1, 2025 to meet all network adequacy requirements in approved counties. We recommend that plans review network adequacy at least every 90 days (30 days when possible) to identify and address any network gaps that emerged after applications were submitted.

Prepare for Triennial Review. Health plans that submitted LOIs in 2023 for PY 2024 are subject to a CMS triennial review in 2024. Plans should conduct mock audits to ensure they’re prepared; this includes reviewing network adequacy to ensure all specialties on the Health Service Delivery (HSD) tables meet CMS time and distance standards.

Build Networks for CY 2026 Initial or Service-area Expansions. Health plans that will submit applications for CY 2026 are required to meet all network adequacy requirements in addition to converting any LOIs and credentialing providers submitted with CY 2025 applications. Plans need to prepare for a triennial audit if LOIs were used for CY 2024 applications and incorporate new network adequacy requirements.

Expand Access to Behavioral Health Providers 

CMS finalized regulatory changes and added several new behavioral health specialties to network adequacy requirements. Regulatory changes include:

  • Outpatient behavioral health is a new facility-specialty provider category and includes a range of behavioral health providers. CMS will include these providers in network adequacy evaluations. The outpatient behavioral health provider category includes:
    • Marriage and family therapists (MFTs)
    • Mental health counselors (MHCs)
    • Opioid treatment programs
    • Community mental health centers
    • Additional medicine specialists and facilities
  • Statutory changes in the Consolidated Appropriations Act of 2023 established new network adequacy standards for MA plans. These include permitting MFTs and MHCs to enroll and start billing Medicare.
  • MA plans are required to independently verify that behavioral health providers furnish services to at least 20 patients within a 12-month period, using reliable information to make this determination. Sources include:
    • MA plan claims data
    • Prescription drug claims data
    • Electronic health records
    • Similar data
  • Outpatient behavioral health facility specialties will receive a ten percent credit toward meeting network adequacy time and distance standards.

Exchange Plan Network Development Requirements

Any health plan that operates on state exchanges will be required to meet time and distance standards for provider access beginning in CY 2026. The standards mirror the requirements for plans operating on the federal exchange. Plans should review networks and begin to prepare to meet these new requirements.

ATTAC Consulting Group helps health plans develop and execute provider network strategies to build and position networks, meet regulatory requirements and enhance marketability. Contact us to learn more about how our expert team can help your plan optimize its network.