The ultimate rule implementing “Contract Yr 2023 Coverage and Technical Adjustments to the Medicare Benefit and Medicare Prescription Drug Profit Packages” is now obtainable for evaluate, and set for publication within the Could 9, 2022 Federal Register. The ultimate rule adopts the proposed change that requires preliminary and repair space growth candidates to submit their proposed contracted networks in the course of the software course of. The ultimate rule delays this variation from contract 12 months 2023 to contract 12 months 2024.
In making this variation, CMS is principally reverting to its course of previous to 2019, when it started permitting plans to attest to community adequacy for brand new contract or service space growth purposes, and relied on its triennial community evaluate course of to guage compliance with community adequacy requirements for brand new and expanded contracts.
CMS expressed concern primarily based on three years of expertise that the attestation-only course of might have an effect on the integrity of the bidding course of. It particularly famous that a lot of plans have requested to scale back the service space recognized of their bid proposal as soon as they realized that they didn’t have a adequate community for a number of counties included within the service space. The quantity recognized as looking for such modifications is small: since 2019, 5 organizations requested to make modifications to the service space of a complete of 10 plans after bid submission deadlines. Nevertheless, in CMS’ view, when a plan has to revise its bid to take away a county, it’s possible that the preliminary bid submission was not full, well timed, or correct.
CMS additionally famous that its post-application community adequacy critiques confirmed a sample of organizations persevering with to have insufficient networks even after their contract grew to become operational. CMS discovered a complete of 19 plans that fell into this class.
The unique problem that prompted the change in 2019 has not gone away, which is the potential problem of candidates securing a full supplier community virtually a 12 months upfront of the contract changing into operational. The appliance is usually submitted in February – round 10 months previous to the contract 12 months that begins on January 1. CMS obtained many feedback in regards to the problem of acquiring ultimate contracts in time for the applying course of, particularly in underserved areas or these with comparatively few suppliers.
CMS acknowledged the validity of plan feedback, and didn’t absolutely clarify why it determined to vary the applying course of for all plans, fairly than utilizing its authority to take measures in opposition to the small variety of plans which have demonstrated an issue with community adequacy compliance – reminiscent of disapproving a request for a brand new contract or service space growth for a plan that seeks to vary its service space after bid submission, or suspending enrollment till an operational plan comes into compliance with community adequacy requirements. As an alternative, CMS will present two sorts of pretty restricted flexibility for organizations to mitigate the affect of the change:
- CMS will permit a 10-percentage level credit score in direction of the share of beneficiaries residing inside revealed time and distance requirements for the contracted community within the pending service space, on the time of software and throughout the applying evaluate.
- CMS will permit plans to make use of letters of intent (LOIs) in lieu of signed supplier contracts, on the time of software and throughout the applying evaluate. The LOI have to be signed by each the MA group and the supplier. Candidates should notify CMS of their use of LOIs to fulfill community requirements.
In the beginning of the contract 12 months (that’s, January 1), this flexibility would not apply, and plans would want to fulfill community adequacy requirements for your entire service space with ultimate, signed supplier and facility contracts.