Helaine I. Fingold, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore office, co-authored an article in AHLA, titled “Medicare Advantage Provider Network Adequacy Regulatory Changes for 2024.” (Read the full version – subscription required.)

Following is an excerpt:

The Centers for Medicare & Medicaid Services (CMS) has recently raised the stakes for entities seeking to newly offer or expand Medicare Advantage products by restructuring the timing and approach to how the agency assesses the adequacy of applicants’ provider and facility networks. Pursuant to the 2023 Medicare Advantage and Part D final rule, Medicare Advantage applicants must now demonstrate the adequacy of their network during the application review process, significantly raising the risk of application denial. In addition, however, the final rule provided certain flexibilities in the assessment process that should make it easier for applicants to show that they meet the standards at that time. In recent years, applicants’ network adequacy was not assessed until after applications were approved, and CMS generally allowed applicants to cure or otherwise address any network weaknesses without risking the applicants’ ability to move forward with their newly approved or expanded offerings. The changes to the network adequacy process take effect with the contract year (CY) 2024 applications, due to CMS in February 2023. ...

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