Physicians Tell Feds: Rework Network Adequacy Plan
By Joey Berlin


The Texas Medical Association and the Texas Pediatric Society (TPS) are urging the Centers for Medicare & Medicaid Services (CMS) to reconsider several parts of its proposal to redefine adequate networks for Medicaid.

TMA and TPS submitted comments urging CMS to change its mind on several aspects of its proposal affecting network adequacy for Medicaid managed care organizations (MCOs). Among the topics TMA and TPS noted in their letter:   

  • Time and distance standards: CMS is proposing to eliminate requirements for states to set time and distance standards that are intended to ensure adequate access to care. In their place the CMS proposal would allow states to set “quantitative” standards, like provider-to-enrollee ratios. TMA and TPS oppose and have “grave concern” about the removal of time and distance standards, and believe using the quantitative standards alone “will leave far too much room for states to employ measurements that have little bearing” on patient access.
  • Specialty access: The CMS proposal asserts the definition of “specialist” for network adequacy purposes should come from each state, not the federal level. TMA and TPS disagree, saying giving states the flexibility to make that determination “will mean inconsistency across the country regarding the level of access to certain specialists” and could allow states to define specialists “in such a way that makes compliance easier.” Noting that Medicaid patients across the nation all require access to specialized health care, TMA urged CMS to retain the current standards for specialty access.
  • Paper network directories: The CMS proposal would allow some managed care organizations to print paper directories less frequently if they have mobilephone applications where patients can access updated directories. TMA and TPS say that change “will lead to confusion and harm patient access to care if patients do not have a ready alternative. … And simply having a smartphone does not mean the owner is technologically savvy enough to navigate a mobile electronic directory, nor does it mean the owner has the data or connectivity to access mobile electronic directories.” TMA recommends that in exchange for allowing those MCOs to make fewer updates to paper directories, CMS require the MCOs to provide real-time assistance in identifying in-network practitioners.    

TMA does support a CMS proposal to allow states to exempt managed care plans from additional Medicaid external quality review if the plan already underwent a review by Medicare. However, TMA is asking CMS to require states that allow this option to include easy online access to those MCOs’ Medicare-conducted quality and access reviews.

Last Updated On

February 08, 2019

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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