CMS requires applicants to demonstrate they have a sufficient network of contracted providers before an initial or service-area expansion application is approved. In addition, for CY 2024, CMS will adopt regulations explicitly permitting it to deny applications based on an applicant’s failure to meet network adequacy criteria.
Plans have already begun submitting Health Service Delivery (HSD) filings through the Health Plan Management System Network Management Module for CY 2024 applications, with the approval process continuing through the summer. For plans planning to apply for new markets or service area expansions in CY 2025, now is the time to start strategizing provider network build strategies.
To obtain approval for initial or service-area expansion applications for Medicare Advantage (MA) plans in CY 2024, CMS requires applicants to demonstrate that they have a sufficient network of contracted providers. Additionally, for CY 2024, CMS will have the explicit authority to deny applications that fail to meet network adequacy criteria.
MA health plans that have submitted CY 2024 applications are addressing network deficiencies while simultaneously planning their initial applications for CY 2025. Provider network submissions for CY 2025 are due to CMS in February 2024.
What changed for CY 2024?
Starting in 2023, CMS will return to the previous MA application process for CY 2024 network submissions and adequacy review, with a few changes.
- CMS can deny an application if the network is not adequate, but it will offer a few allowances to help plans meet network adequacy in the shorter timeframe, such as a 10% credit for the initial CY 2024, a 10% telehealth credit, a 10% certificate of need credit, and a 10% network adequacy credit for meeting requirements in the initial phase.
It is expected (but not confirmed) that these network adequacy credit percentages will be in addition to the initial network-build credit, telehealth credit, and certificate of need credit based on the network submitted.
Since CMS provides credits towards meeting member access percentages for selected specialties, plans should verify their telehealth offerings for each specialty and make additions where appropriate.
- Letters of intent (LOIs) may be used for initial submission, but MA organizations must notify CMS of their intent to use LOIs to meet network adequacy requirements. MA organizations that use LOIs will automatically be included in triennial reviews (currently “luck of the draw”).
- MA organizations must be fully compliant by January 2, 2024, as LOIs will no longer be allowed to meet adequacy requirements, and providers must be fully contracted and credentialed. The 10% credit no longer applies, and provider networks must meet network adequacy requirements.
The timeline for CY 2024 application (network) is as follows:
The aggressive timeline to complete and finalize your plan’s CY 2024 provider network is expected to strain health plan resources, especially for plans planning on CY 2025 applications and provider network submissions. ATTAC Consulting Group’s provider network strategy and contracting experts can help your plan tackle this aggressive timeline, including converting LOIs to fully contracted/credentialed providers and filling any gaps from the 10% credit.