The ultimate rule implementing “Contract 12 months 2023 Coverage and Technical Modifications to the Medicare Benefit and Medicare Prescription Drug Profit Applications” is now out there for overview, and set for publication within the Could 9, 2022 Federal Register. The ultimate rule adopts the proposed change that requires preliminary and repair space enlargement candidates to submit their proposed contracted networks through 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 spanking new contract or service space enlargement functions, and relied on its triennial community overview course of to judge compliance with community adequacy requirements for brand spanking new and expanded contracts.
CMS expressed concern based mostly 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 plenty 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 ample community for a number of counties included within the service space. The quantity recognized as in search of such adjustments is small: since 2019, 5 organizations requested to make adjustments 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 turned operational. CMS discovered a complete of 19 plans that fell into this class.
The unique concern 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 turning into operational. The applying is usually submitted in February – round 10 months previous to the contract 12 months that begins on January 1. CMS acquired many feedback in regards to the problem of acquiring ultimate contracts in time for the appliance course of, particularly in underserved areas or these with comparatively few suppliers.
CMS acknowledged the validity of plan feedback, and didn’t totally clarify why it determined to vary the appliance course of for all plans, moderately than utilizing its authority to take measures in opposition to the small variety of plans which have demonstrated an issue with community adequacy compliance – resembling disapproving a request for a brand new contract or service space enlargement 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 a substitute, CMS will present two kinds of pretty restricted flexibility for organizations to mitigate the impression of the change:
- CMS will permit a 10-percentage level credit score in the 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 appliance overview.
- 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 appliance overview. 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.
At the start of the contract 12 months (that’s, January 1), this flexibility would not apply, and plans would want to fulfill community adequacy requirements for all the service space with ultimate, signed supplier and facility contracts.
