Access and Availability Rules for Coordinated Care Plans

110.1 – Access and Availability Rules for Coordinated Care Plans (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) An MA plan may specify the providers through whom enrollees may obtain services if it ensures that all original Medicare covered services and supplemental benefits contracted for, by, or on behalf of Medicare enrollees are available and accessible under the coordinated care requirements. Plans are required to maintain and monitor a network of appropriate providers, supported by written arrangements, that is sufficient to provide adequate access to covered services to meet the needs of the population served. This involves ensuring that services are geographically accessible and consistent with local community patterns of care. In other words, the plan must ensure that contracted providers are distributed so that no enrollee residing in the service area must travel an unreasonable distance to obtain covered services. CMS standards for access are provided by the Health Service Delivery (HSD) tables used to evaluate plan networks during the initial application, service area expansion application, and continued operations throughout the contract year. The HSD process uses a mostly automated process to measure access by county and specialty. The assessment measures used include measuring the number of providers, as well as the average distance and time needed for enrollees to access each provider and facility in each county. All MAOs are expected to continuously monitor their networks to ensure compliance with contractual obligations and in accordance with 42 CFR 422.112(a)(1)(i). CMS encourages MAOs to use the “organization-initiated” automated review feature in the Network Management Module (NMM) in HPMS. For more information, please refer to the December 23, 2015, HPMS memo “Release of Network Management Module in Health Plan Management System (HPMS).” In addition, as part of this continuous network self-monitoring, CMS expects that if an MAO becomes aware of network deficiencies at any time or believes that an exception is warranted for a particular specialty in a given service area, then the MAO will alert its CMS Account Manager.