Medicare Health Plans: Network Adequacy
Guidance for network adequacy for Medicare Advantage organizations offering coordinated care plans, network-based private fee-for-service plans, and network-based medical savings account plans, as well as section 1876 cost organizations.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: March 05, 2012
Medicare Advantage (MA) organizations offering coordinated care plans, network-based private fee-for-service (PFFS) plans, and network-based medical savings account (MSA) plans, as well as section 1876 cost organizations, must maintain a network of appropriate providers that is sufficient to provide adequate access to covered services to meet the needs of the population served. The contracted network of providers must be consistent with the pattern of care in the network service area.
MA regional preferred provider organizations (RPPOs) are an exception and, under specified conditions and CMS approval, can arrange for care in portions of a regional service area on a non-network basis. The service area of an RPPO is defined as one or more entire regions, consisting of one or more states. In the "Downloads" section below, click on “RPPO MA Regions” to view the CMS RPPO regions.
PFFS plans’ network areas are those where at least two network-based plans are operating with enrollment for a given plan year. In the Annual Announcement of Medicare Advantage Capitation Rates, CMS publishes a list of network areas applicable two contract years in the future. In the “Related Links” section below, click on “PFFS Plan Network Requirements” to see the network areas for non-employer PFFS plans.
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