Notification to CMS

110.1.2.2 – Notification to CMS (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) An MAO must notify its CMS Account Manager of any no-cause provider termination that the MAO deems to be significant, at least 90 days prior to the effective date of the termination. To the extent possible, CMS would like to ensure that appropriate contingency planning is in place prior to an MAO making any significant network change. For example, an MAO should notify its Account Manager if it is in current contract negotiations with a provider group that would have a significant impact on the network if the negotiations were not successfully concluded. CMS expects MAOs to take a conservative approach in determining whether a network change is significant by notifying CMS if there is any doubt as to whether the no-cause provider termination represents significant change to the network. This prior notification facilitates CMS oversight and verification of MAO compliance with current CMS network adequacy standards. An MAO that does not notify CMS of network changes that are ultimately deemed significant will be subject to appropriate compliance actions. Upon CMS notification, CMS may ask the MAO to provide additional information about the network change, and CMS will verify whether the network change is indeed significant. If CMS deems the MAO’s network change to be significant, then CMS may ask the MAO to demonstrate its continued compliance with current CMS network adequacy standards through the submission of HSD tables to the NMM. CMS may also ask the MAO to submit a written plan that provides a detailed description of the steps the MAO will take to ensure that affected enrollees are able to locate new providers that meet their individual needs and describe how continuity of care would be maintained for affected enrollees. MAOs would also provide, upon request, information about the number and outcome of continuity of care requests that they receive so that CMS may confirm that the MAO is in compliance with all applicable requirements. In addition, CMS may require the MAO to augment its network by contracting with additional providers to meet network adequacy standards or, if necessary in order to meet immediate access needs, to allow enrollees to access care from non-contracted providers and limit enrollee cost-sharing to in-network amounts. Furthermore, it may be necessary for MAOs to allow care to continue to be furnished on an interim, transitional basis, by providers who have been terminated from the network in order to adequately address continuity of care needs for affected enrollees.