RADAR on Medicare Advantage

Lauren Flynn Kelly

CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services Informational Bulletin (CIB) are templates that provide a standard format for states to report managed care medical loss ratios and network adequacy to determine how well a plan actually delivers its benefits. As plans struggle to meet network adequacy standards, the new template could lead to more intense oversight of network adequacy within managed care, industry experts suggest.

After CMS initially proposed to set time and distance standards for determining the adequacy of MCOs’ provider networks, the agency in a November 2020 final rule said it would instead establish “quantitative” standards that allow states to use alternative metrics such as the “provider to enrollee ratio.” Effective July 1, 2018, states were to begin submitting information assuring CMS that its MCOs meet the state’s requirements for availability of services and including documentation of an analysis to support that compliance. But up until now there has been no standard reporting template, and starting Oct. 1, states will be required to use one. CMS recommends that the report be submitted as supporting documentation at the same time a state submits the associated managed care contract to CMS for approval, including a new contract, a renewal, or an amendment.

To Jocelyn Bayliss of ATTAC Consulting Group, there are pros and cons associated with the new process. “For example, having each State submit a Network Adequacy and Assurances Report in a consistent template and providing attestation should provide CMS with each of the State standards and high-level outcomes by state; however, the variables by state need to be factored in and the actual analysis reports the States are required to submit do not seem to have a standard format,” Bayliss observes in an email to AIS Health, a division of MMIT.

“Something else to consider, is that provider and specialty types and standards across each of the State programs (e.g., Medicaid, CHIP and MMP [Medicare-Medicaid Plan] programs) can vary,” she continues. “Health plans typically create crosswalks to ensure they are reporting the information accurately between federal, state and local program requirements.”

Meeting network adequacy, particularly in the area of behavioral health, has proven to be a challenge in recent years for health plans. A recent Health Affairs study of Oregon’s Medicaid managed care program found significant discrepancies between the providers listed in directories and those who can be accessed by managed care enrollees and suggested that “provider network monitoring and enforcement may fall short if based on directory information.” Meanwhile, Molina Healthcare, Inc. recently agreed to pay $4.625 million to resolve mental health provider licensing and supervision shortcomings.

“Network adequacy and availability has been impacted significantly in the last couple years with provider offices being short staffed, provider shortages and retirement due to the pandemic and increased cost of living. I can see the benefit of having transparency and a centralized repository of the standards for all constituents if the reports are publicly available,” says Bayliss. “This will help identify trends and identify key shortage areas between federal and state programs across the nation related to provider access and availability standards and outcomes.”

She adds, “Overall, I believe this is a step in the right direction to create uniformity and visibility in network adequacy and availability impacting patient access to care. It will be interesting to see how this data and results are utilized and shared in the future.”

Kacey Dugan, director of policy and regulatory affairs with Faegre Drinker Consulting, agrees that this is a positive step. “Within the larger context of increased scrutiny on not just Medicaid plans but MA plans and QHPs in terms of their meeting network adequacy and ensuring access to care, I think that this gives CMS a better window into the extent to which states are overseeing network adequacy among their plans,” Dugan tells AIS Health.

“It gets CMS closer to being able to oversee states as they oversee their plans, whereas it has taken a more of a hands-off approach of relying on states to make sure their plans are compliant,” she adds. “CMS is interested in ensuring network adequacy and access to care.…and I think this reflects a larger pattern toward potentially greater oversight of network adequacy.”

Contact Bayliss at jbayliss@attacconsulting.com and Dugan at kacey.dugan@faegredrinker.com.