An MA organization that offers an MA coordinated care plan may specify the networks of providers from whom enrollees may obtain services if the MA organization ensures that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan. To accomplish this, the MA organization must meet the following requirements:
- Provider network. Maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to covered services to meet the needs of the population served. These providers are typically used in the network as PCPs, specialists, hospitals, skilled nursing facilities, home health agencies, ambulatory clinics and other providers. MA regional plans, upon CMS pre-approval, can use methods other than written agreements to establish that access requirements are met.
- PCP panel. Establish a panel of PCPs from which the enrollee may select a PCP. If an MA organization requires its enrollees to obtain a referral in most situations before receiving services from a specialist, the MA organization must either assign a PCP for purposes of making the needed referral or make other arrangements to ensure access to medically necessary specialty care.
- Specialty care. Provide or arrange for necessary specialty care, and in particular give women enrollees the option of direct access to a women’s health specialist within the network for women’s routine and preventive health care services provided as basic benefits. The MA organization arranges for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee’s medical needs.
- Service area expansion. If seeking a service area expansion for an MA plan, demonstrate that the number and type of providers available to plan enrollees are sufficient to meet projected needs of the population to be served.
- Credentialed providers. Demonstrate to CMS that its providers in an MA plan are credentialed.
- Hours of operation. Ensure that:
- The hours of operation of its MA plan providers are convenient to the population served under the plan and do not discriminate against Medicare enrollees.
- Plan services are available 24 hours a day, 7 days a week, when medically necessary.
- Cultural considerations. Ensure that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds.
- Ambulance services, emergency and urgently needed services, and post-stabilization care services coverage. Provide coverage for ambulance services, emergency and urgently needed services, and post-stabilization care services.
- Ensure that the MA organization and its provider network have the information required for effective and continuous patient care and quality review, including procedures to ensure that:
- The MA organization makes a “best-effort” attempt to conduct an initial assessment of each enrollee’s health care needs, including following up on unsuccessful attempts to contact an enrollee, within 90 days of the effective date of enrollment.
- Each provider, supplier and practitioner furnishing services to enrollees maintains an enrollee health record in accordance with standards established by the MA organization, taking into account professional standards.
- There is appropriate and confidential exchange of information among provider network components.