Modernizing Network Composition

Consumers deserve access to a network of high-quality clinicians delivering the right care at the right time, achieving the best outcomes. Access should be measured by standards that reflect modern approaches to care delivery. In today’s Medicare Advantage (MA), the adequacy of a consumer’s provider network is measured by the number and type of providers located within specific, often stringent, distances from the consumer’s home. That is simply outdated—a large and growing share of physical and mental health care appointments are not completed through a traditional “office visit.” Virtual and team-based health care are game changers, allowing clinicians to work to the top of their license, partner with care teams for the patient and address workforce shortages, especially in rural and underserved areas. We live in a digital era and consumers expect nothing less than convenient, 24/7 access to health care. 

MA for Tomorrow modernizes network composition by establishing contemporary network adequacy standards. Outdated network adequacy standards based on time and distance are replaced with standards that recognize innovations in care delivery such as virtual care and remote monitoring, as well as other measures of provider accessibility. MA for Tomorrow will modernize network composition by:  

1. Leveraging Virtual Care in Measuring Network Adequacy 

Current network adequacy requirements fail to fully recognize a health plan’s ability to utilize virtual care to form comprehensive provider networks, serving consumers where they are and when they need services. Today, only ten percent of a health plans network may be comprised of virtual care, limiting the ability to expand care delivery in rural and underserved areas struggling with workforce shortages. Consumers may be able to find an appointment sooner with a provider virtually, particularly if they are seeking on-demand or same-day care. Innovative care delivery through virtual care should be incentivized, not punished based on outdated network adequacy standards. 

MA for Tomorrow recognizes the success of virtual care by expanding the percent of a health plan network that can be comprised of virtual care providers from 10 to 30 percent. Additionally, MA for Tomorrow allows appointment wait time requirements to be satisfied with virtual care availability, reflecting that virtual care on-demand and same day-virtual appointments are not captured within the current appointment wait time metrics. For consumers across the country, particularly in rural and frontier regions, virtual care has been a game changer, improving services and availability. CMS has the authority to allow health plans to leverage virtual care in network composition and should update network adequacy requirements.  

2. Streamlining Network Adequacy Exceptions Process 

Network adequacy is measured at the county level, creating circumstances where a health plan may need an exception in order to offer a plan. Obtaining a network adequacy exception is a complex, opaque process. With stringent criteria for meeting network adequacy requirements, there is little flexibility for geographic, market or access variables. This is particularly a challenge in communities where insurmountable provider shortages or market challenges exist, potentially limiting health plans from expanding into new areas and offering seniors more choice. 

MA for Tomorrow streamlines the network adequacy exception process and outlines clear, expanded criteria for appropriate exceptions. CMS has the authority to delineate clear criteria when a health plan faces contracting, marketing or geographic challenges in meeting all network adequacy requirements. A transparent and straightforward exceptions process will increase competition and consumer choice, particularly in areas that have previously had limited MA plan offerings. 

3. Creating a ‘Pick Two’ Option to Demonstrate Network Adequacy  

Network adequacy is currently measured on a health plan’s ability to achieve time and distance guidelines, provider ratio requirements and appointment wait time standards. These requirements, particularly time and distance, are inaccurate reflections of whether a health plan can meaningfully offer a consumer timely and accessible care. Reflecting advances in care delivery technology, consumer expectations and workforce shortages, network adequacy measurement must be modernized with additional opportunities to demonstrate satisfactory network composition. 

MA for Tomorrow introduces additional criteria that allow a health plan to achieve network adequacy. Health plans can choose to continue using the current time and distance, provider ratio and appointment wait time requirements. MA for Tomorrow creates a ‘Pick Two’ option providing health plans additional opportunities to establish network adequacy. Under this approach, health plans would pick two of the current metrics and two of the following new metrics:  

a. At least ten percent of health plan’s contracted primary care providers/locations have after-hours care  

b. Health plan offers consumers 24/7 clinical support services 

c. For a renewing health plan, the MA contract must have achieved 4+ star rating for Patient Access and Outcome metrics 

CMS has the authority to introduce more options for health plans to demonstrate sufficient network adequacy, creating opportunities for additional consumer choice in hard to serve areas. When health plans compete, consumers win. Modernized network composition standards allow more health plans to participate and offer innovative benefits for consumers.