General

110.1.2.1 – General (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) When MAOs submit PBPs for CMS’ review and approval, they attest that the benefits included in those packages “…will be offered in accordance with all applicable Medicare program authorizing statutes and regulations and program guidance that CMS has issued to date…” Thus, MAOs’ PBPs for the upcoming contract year must meet, and continue to meet, CMS network adequacy standards, as outlined in the guidance in this chapter and current MA HSD Network Adequacy Criteria Guidance, which can be found on the MA Applications webpage at: https://www.cms.gov/MedicareAdvantageApps. See 42 CFR §422.112(a)(1)(i). MAOs have considerable discretion to select the providers with whom to contract in order to build high-performing, cost effective provider networks. They are able to make changes to these networks at any time during the contract year, as long as they continue to furnish all Medicare-covered services in a non-discriminatory manner, meet established access and availability standards and timely notice requirements, and ensure continuity of care for enrollees. CMS recognizes that significant no-cause network changes may occur during the contract year. MAOs may be in the best position to determine whether or not a provider termination without cause is significant. CMS considers significant changes to provider networks to be those that go beyond individual or limited provider terminations that occur during the routine course of plan operations and affect, or have the potential to affect, a large number of the MAO’s enrollees. Please note: Significant network changes could result from any no-cause provider termination, whether it is initiated by the MAO or the provider. In addition, significant network changes could result from no-cause provider terminations that are effective at any point during the contract year, whether it is mid-year or on January 1.