Pre-2016 Medicare Advantage network adequacy guidance simply states that plans must maintain a network of providers “sufficient to provide adequate access to covered services to meet the needs of the population served” and establish written rules on timeliness of access to care in accordance with CMS standards. Of course, this ambiguity has led to numerous interpretations and applications.

Combine this ambiguity with seven major litigation cases concerning provider directory accuracy occurring in 2014 and the findings of the GAO report released in 2015, and you have the release of significantly strengthened provider directory accuracy and network adequacy requirements as per CMS’ MAO Final Call Letter issued on April 6th.

The new provider directory requirements, which officially went into effect June 1st of 2016, indicate that MA plans must:

• Conduct quarterly outreach to providers regarding their network status and to verify where or not they are accepting new patients
• Ensure directories are available in machine readable format
• Ensure directories are compliant with §§ 422.111 and 422.112
• Include all active contracted providers in their online provider directories, with specific notations to highlight those providers who are closed or not accepting new patients
• Maintain and monitor a network of appropriate providers supported by written agreements and sufficient to provide adequate access to covered services to meet the needs of the population served [42 C.F.R. § 422.112 (a)(1)
• Have a process to effectively address inquiries/complaints related to enrollees being denied access to a contracted provider with follow through corrections to the online directory
• Update online directories within 30 days of data error or change notification

Concerning network adequacy, the 2016 Final Call Letter states that MAO’s must:

• Establish and maintain a proactive, structured process that enables them to assess, on a timely basis, the true availability of contracted providers and their ability to provide a sufficient level of care
• Maintain and monitor a network of appropriate providers supported by written agreements and sufficient to provide adequate access to covered services to meet the needs of the population served [42 C.F.R. § 422.112 (a)(1)
• Disclose the number, mix and distribution (addresses) of providers from who enrollees can receive services from [42 C.F.R. § 422.111 (b)(3)(i)]

*These requirements were also included in the 2016 Medicare Marketing Guidelines.

Reference: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdf