CHANGES TO NETWORK ADEQUACY AND PROVIDER DIRECTORIES

OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) issued its Contract Year 2025 Medicare Advantage and Part D Final Rule on April 23, 2024. Notably, this comprehensive rule introduces a new Outpatient Behavioral Health facility-specialty type into the network adequacy standards and creates two network adequacy exception bases solely for facility-based Institutional Special Needs Plans (I-SNPs). In this policy brief, we provide a comprehensive overview of the changes and how they may influence Medicare Advantage Organizations (MA organizations), focusing on network adequacy and provider directory accuracy.

Facility-Specialty Type
Outpatient
Behavioral Health

Verify Provider Activity

Network Adequacy Exception Rationales
for Facility-Based I-SNPs

NEW FACILITY-SPECIALTY TYPE

OUTPATIENT BEHAVIORAL HEALTH

CMS added “Outpatient Behavioral Health” as a facility-specialty type. Starting January 1, 2025, this specialty type will be part of the network adequacy review for MA organizations. The Outpatient Behavioral Health category includes the following:

Specialties Under the Outpatient Behavioral Health Category

• Marriage and Family Therapists
• Mental Health Counselors
• Opioid Treatment Programs
• Community Mental Health Centers
• Psychotherapy or Prescription of Medication for Substance Use Disorders, including:
• Addiction Medicine Physicians
— Physician Assistants (PAs)
• Outpatient Mental Health and Substance Use Treatment Facilities
— Nurse Practitioners (NPs)
— Clinical Nurse Specialists (CNSs)

All applicable state and federal laws about the practice of medicine and delivery of health care services must be met, and
specific healthcare professionals must be appropriately licensed or certified to furnish the applicable services.

NETWORK ADEQUACY CRITERIA

CMS will evaluate Outpatient Behavioral Health using MA Network Adequacy standards.

• Maximum Time and Distance
• Minimum Number of Facility-Specialty Type in Each County

ELIGIBLE FOR TELEHEALTH CREDIT

Outpatient Behavioral Health is eligible for a 10-percentage point credit toward the network adequacy time and distance standards for MA plans. This credit is applicable when an MA organization’s contracted network includes telehealth providers who offer additional telehealth benefits, beyond what is stipulated in the statute, for covered services in the Outpatient Behavioral Health specialty.

HEALTH SERVICE DELIVERY (HSD) TABLE GUIDELINES

INCLUSION OF OUTPATIENT

BEHAVIORAL HEALTH

MA organizations are evaluated for network adequacy during the initial application process, service area expansions, and triennial reviews. Outpatient Behavioral Health will be included in the Health Services Delivery (HSD) table as part of the network review process.

LIMITS ON PROVIDER SUBMISSIONS

MA organizations are restricted from using a single provider to fulfill multiple provider network requirements. For example, a provider cannot be listed as a psychiatry, clinical social work, or clinical psychologist provider specialty, and also as an Outpatient Behavioral Health facility.

A provider cannot be double-counted across different provider categories in HSD tables.

DR. JOPLIN IS FULFILLING ONLY ONE
PROVIDER NETWORK REQUIREMENT

REQUIREMENTS TO ADDRESS

GHOST NETWORK CONCERNS

To fulfill these standards, PAs, NPs, and CNSs are required to demonstrate evidence of providing behavioral health counseling or therapy services to a minimum of 20 patients within the last 12 months.

“To address concerns that NPs, PAs, and
CNSs might lack the necessary skills,
training, or expertise to effectively address
the behavioral health needs of enrollees
and that the absence of criteria for
incorporating these provider types could
result in the creation of “ghost networks”,
where providers may be listed in a provider
directory without actively treating patients
for behavioral health, we are also adopting
specific criteria that MA organizations must
use to determine when an NP, PA or CNS
can be considered part of a network to meet
the Outpatient Behavioral Health network
adequacy standard. MA organizations must
independently verify that the provider
has furnished or will furnish such services
to 20 patients within a recent 12-month
period using reliable information about
services furnished by the provider such
as the MA organization’s claims data,
prescription drug claims data, electronic
health records, or similar data.”

— CMS, Contract Year 2025 Medicare
Advantage and Part D Final Rule

ANNUAL VERIFICATION RESPONSIBILITIES

MA organizations must independently verify that this standard is met by every NP, PA, and/or CNS it intends to submit for purposes of the Outpatient Behavioral Health. Verification can be done by analyzing reliable information about services furnished by the providers, such as:

• MA Organization’s Claims Data
• Prescription Drug Claims Data
• Electronic Health Records
• Similar Data

The data analysis must be performed at least once a year, focusing on a recent 12-month period and completed ahead of the CMS evaluation process.

HANDLING PROVIDERS WITH INSUFFICIENT

PREVIOUS PRACTICE EXPERIENCE

If there is insufficient evidence of these provider types having previous practice experience sufficient to meet the threshold of 20 patients within a recent 12-month period, MA organizations must have a reasonable and supportable basis for concluding that the provider will meet the threshold in the next 12 months.

If an NP, PA, or CNS is new to independent practice (and therefore doesn’t have the appropriate claims record in previous years), has received psychiatry or addiction medicine specialized training, and is listed as a psychiatry or addiction medicine NP, PA, or CNS on public-facing websites, this would be a reasonable and supportable basis for concluding that the practitioner would meet the requirement in the next 12 months. Therefore, the practitioner could be utilized toward meeting network adequacy standards for Outpatient Behavioral Health.

SUBMISSION OF EVIDENCE TO CMS

MA organizations are required to submit corroborated evidence to CMS upon request. This documentation should substantiate that the PA, NP, and/or CNS has delivered or is expected to deliver at least one of the specified psychotherapy or medication prescriptions to a minimum of 20 patients. All submissions should conform to the format and manner specified by CMS.

NEW NETWORK ADEQUACY EXCEPTION RATIONALES FOR FACILITY-BASED I-SNPs

CMS finalized new provisions for facility-based Institutional Special Needs Plans (I-SNPs) to simplify their compliance with network adequacy requirements. The rule recognizes the unique challenges of facility-based I-SNPs and introduces two distinct bases for requesting exceptions to standard network adequacy criteria.

BASIS 1: INABILITY TO CONTRACT WITH REQUIRED SPECIALTY TYPES

CMS has defined “inability to contract” with certain specialty types as a valid reason for an exception to network adequacy requirements. This situation arises when a facility-based I-SNP cannot successfully negotiate contracts with required specialty providers. To be granted an exception, the I-SNP must provide concrete evidence, such as written communications, that demonstrate efforts to contract with and refusals by such providers. This provision addresses the practical difficulties encountered by facility-based I-SNPs due to their specialized care delivery models.

For example, MA organizations could submit
correspondence, such as letters or emails, exchanged with
providers’ offices showing that these providers declined to
contract with any facility-based I-SNP.

BASIS 2: SUFFICIENT ACCESS TO BASIC BENEFITS THROUGH ADDITIONAL TELEHEALTH BENEFITS

The second rationale for an exception is predicated on the facility-based I-SNP’s ability to provide comprehensive access to basic benefits predominantly through telehealth services. This basis acknowledges the efficacy of telehealth in meeting the healthcare needs of facilitybased I-SNP enrollees. For an exception to be considered under this rationale, the I-SNP must substantiate that it offers adequate telehealth services to substitute for in-person care and maintain the requisite standards of network adequacy.

Additionally, the I-SNP must ensure coverage for outof-network services delivered in person at the same in-network cost-sharing rates when such services are requested by the enrollee.

A FINAL NOTE ON CMS OVERSIGHT

It’s crucial to underscore the importance of maintaining continuous compliance with CMS regulations related to network adequacy and provider directory accuracy. MA organizations are reminded of their obligation to adhere to federal laws mandating year-round monitoring and maintenance of network adequacy and provider directory accuracy.

COMPLIANCE REMINDERS AND CHANGES

Ongoing Vigilance: Promptly report any issues of noncompliance or major changes in your provider network to your CMS Account Manager.

Shifting Standards: The criteria for provider directory accuracy are increasing, imposing stricter requirements.

KEY CHANGES TO NOTE

• Rolling 90-Day Update Cycle: A shift to a 90-day cycle for the verification and updating of provider directories, moving away from the annual updates.

• Enhanced Directory Searchability: Obligation for provider directories to be fully searchable by all required data elements outlined in the model provider directory.

• Broadened Data Verification: The expanded requirement to authenticate additional provider information, including cultural and linguistic details.

ENHANCED CMS

COMPLIANCE MONITORING

Aiming for improved transparency and heightened consumer confidence, CMS is intensifying its provider directory oversight. MA organizations are expected to integrate these elevated standards into their workflows and substantiate their compliance during CMS assessments.

The dynamic environment of network adequacy and provider directory accuracy calls for a forward-thinking and rule-abiding approach by MA organizations. By meeting CMS’s revised directives, these organizations can make a marked difference in fortifying the dependability and trust in their Medicare Advantage offerings.