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GAO to CMS: Amend Network Adequacy Criteria for MA Plans

The U.S. Government Accountability Office (GAO) called on the Centers for Medicare & Medicaid Services (CMS) to amend network adequacy criteria for Medicare Advantage (MA) plans. Recent narrowing of provider networks in MA organizations, which privately offer one or more health benefit plans, has caused concerns over whether MA enrollees can adequately access care. Network adequacy criteria for MA plans currently only determine compliance by taking into account the number of providers and the travel time and distance it takes to receive care. Other network-based health programs, like Medicaid managed care and TRICARE, also include measures of provider availability to determine network adequacy.

GAO also urged CMS to verify information provided by MA organizations and conduct a periodic review of MA organization network adequacy. Currently, CMS only reviews network adequacy compliance when MA organizations propose to enter a new county in an upcoming year.

Finally, GAO recommends that CMS set requirements for notification letters that MA organizations must send to enrollees announcing the termination of contracts with providers, in addition to submission of sample letters to CMS for review.

If you have questions or concerns, please contact Erin O’Malley, director of policy, at eomalley@essentialhospitals.org or 202.585.0127.

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About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.