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Title 42

Displaying title 42, up to date as of 9/23/2021. Title 42 was last amended 9/15/2021.

Title 42

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§ 422.116 Network adequacy.

(a) General rules -

(1) Access.

(i) A network-based MA plan, as described in § 422.114(a)(3)(ii) but not including MSA plans, must demonstrate that it has an adequate contracted provider network that is sufficient to provide access to covered services in accordance with access standards described in section 1852(d)(1) of the Act and in §§ 422.112(a) and 422.114(a)(1) and by meeting the standard in paragraph (a)(2) of this section. When required by CMS, an MA organization must attest that it has an adequate network for access and availability of a specific provider or facility type that CMS does not independently evaluate in a given year.

(ii) CMS does not require information, other than an attestation, regarding compliance with § 422.116 as part of an application for a new or expanding service area and will not deny application on the basis of an evaluation of the applicant's network for the new or expanding service area.

(2) Standards. An MA plan must meet maximum time and distance standards and contract with a specified minimum number of each provider and facility-specialty type.

(i) Each contract provider type must be within maximum time and distance of at least one beneficiary (in the MA Medicare Sample Census) in order to count toward the minimum number.

(ii) The minimum number criteria and the time and distance criteria vary by the county type.

(3) Applicability of MA network adequacy criteria.

(i) The following providers and facility types do not count toward meeting network adequacy criteria:

(A) Specialized, long-term care, and pediatric/children's hospitals.

(B) Providers that are only available in a residential facility.

(C) Providers and facilities contracted with the organization only for its commercial, Medicaid, or other products.

(ii) [Reserved]

(4) Annual updates by CMS. CMS annually updates and makes the following available:

(i) A Health Service Delivery (HSD) Reference file that identifies the following:

(A) All minimum provider and facility number requirements.

(B) All provider and facility time and distance standards.

(C) Ratios established in paragraph (e) of this section in advance of network reviews for the applicable year.

(ii) A Provider Supply file that lists available providers and facilities and their corresponding office locations and specialty types.

(A) The Provider Supply file is updated annually based on information in the Integrated Data Repository (IDR), which has comprehensive claims data, and information from public sources.

(B) CMS may also update the Provider Supply file based on findings from validation of provider information submitted on Exception Requests to reflect changes in the supply of health care providers and facilities.

(b) Provider and facility-specialty types. The provider and facility-specialty types to which the network adequacy evaluation under this section applies are specified in this paragraph (b).

(1) Provider-specialty types. The provider-specialty types are as follows:

(i) Primary Care.

(ii) Allergy and Immunology.

(iii) Cardiology.

(iv) Chiropractor.

(v) Dermatology.

(vi) Endocrinology.

(vii) ENT/Otolaryngology.

(viii) Gastroenterology.

(ix) General Surgery.

(x) Gynecology, OB/GYN.

(xi) Infectious Diseases.

(xii) Nephrology.

(xiii) Neurology.

(xiv) Neurosurgery.

(xv) Oncology - Medical, Surgical.

(xvi) Oncology - Radiation/Radiation Oncology.

(xvii) Ophthalmology.

(xviii) Orthopedic Surgery.

(xix) Physiatry, Rehabilitative Medicine.

(xx) Plastic Surgery.

(xxi) Podiatry.

(xxii) Psychiatry.

(xxiii) Pulmonology.

(xxiv) Rheumatology.

(xxv) Urology.

(xxvi) Vascular Surgery.

(xxvii) Cardiothoracic Surgery.

(2) Facility-specialty types. The facility specialty types are as follows:

(i) Acute Inpatient Hospitals.

(ii) Cardiac Surgery Program.

(iii) Cardiac Catheterization Services.

(iv) Critical Care Services - Intensive Care Units (ICU).

(v) Surgical Services (Outpatient or ASC).

(vi) Skilled Nursing Facilities.

(vii) Diagnostic Radiology.

(viii) Mammography.

(ix) Physical Therapy.

(x) Occupational Therapy.

(xi) Speech Therapy.

(xii) Inpatient Psychiatric Facility Services.

(xiii) Outpatient Infusion/Chemotherapy.

(3) Removal of a provider or facility-specialty type. CMS may remove a specialty or facility type from the network adequacy evaluation for a particular year by not including the type in the annual publication of the HSD reference file.

(c) County type designations. Counties are designated as a specific type using the following population size and density parameters:

(1) Large metro. A large metro designation is assigned to any of the following combinations of population sizes and density parameters:

(i) A population size greater than or equal to 1,000,000 persons with a population density greater than or equal to 1,000 persons per square mile.

(ii) A population size greater than or equal to 500,000 and less than or equal to 999,999 persons with a population density greater than or equal to 1,500 persons per square mile.

(iii) Any population size with a population density of greater than or equal to 5,000 persons per square mile.

(2) Metro. A metro designation is assigned to any of the following combinations of population sizes and density parameters:

(i) A population size greater than or equal to 1,000,000 persons with a population density greater than or equal to 10 persons per square mile and less than or equal to 999.9 persons per square mile.

(ii) A population size greater than or equal to 500,000 persons and less than or equal to 999,999 persons with a population density greater than or equal to 10 persons per square mile and less than or equal to 1,499.9 persons per square mile.

(iii) A population size greater than or equal to 200,000 persons and less than or equal to 499,999 persons with a population density greater than or equal to 10 persons per square mile and less than or equal to 4,999.9 persons per square mile.

(iv) A population size greater than or equal to 50,000 persons and less than or equal to 199,999 persons with a population density greater than or equal to 100 persons per square mile and less than or equal to 4999.9 persons per square mile.

(v) A population size greater than or equal to 10,000 persons and less than or equal to 49,999 persons with a population density greater than or equal to 1,000 persons per square mile and less than or equal to 4999.9 persons per square mile.

(3) Micro. A micro designation is assigned to any of the following combinations of population sizes and density parameters:

(i) A population size greater than or equal to 50,000 persons and less than or equal to 199,999 persons with a population density greater than or equal to 10 persons per square mile and less than or equal to 99.9 persons per square mile.

(ii) A population size greater than or equal to 10,000 persons and less than or equal to 49,999 persons with a population density greater than or equal to 50 persons per square mile and less than 999.9 persons per square mile.

(4) Rural. A rural designation is assigned to any of the following combinations of population sizes and density parameters:

(i) A population size greater than or equal to 10,000 persons and less than or equal to 49,999 persons with a population density of greater than or equal to 10 persons per square mile and less than or equal to 49.9 persons per square mile.

(ii) A population size less than 10,000 persons with a population density greater than or equal 50 persons per square mile and less than or equal to 999.9 persons per square mile.

(5) Counties with extreme access considerations (CEAC). For any population size with a population density of less than 10 persons per square mile.

(d) Maximum time and distance standards -

(1) General rule. CMS determines and annually publishes maximum time and distance standards for each combination of provider or facility specialty type and each county type in accordance with paragraphs (d)(2) and (3) of this section.

(i) Time and distance metrics measure the relationship between the approximate locations of beneficiaries and the locations of the network providers and facilities.

(ii) [Reserved]

(2) By county designation. The following base maximum time (in minutes) and distance (in miles) standards apply for each county type designation, unless modified through customization as described in paragraph (d)(3) of this section.

Table 1 to Paragraph (d)(2)

Provider/Facility type Large
metro
Metro Micro Rural CEAC
Max
time
Max
distance
Max
time
Max
distance
Max
time
Max
distance
Max
time
Max
distance
Max
time
Max
distance
Primary Care 10 5 15 10 30 20 40 30 70 60
Allergy and Immunology 30 15 45 30 80 60 90 75 125 110
Cardiology 20 10 30 20 50 35 75 60 95 85
Chiropractor 30 15 45 30 80 60 90 75 125 110
Dermatology 20 10 45 30 60 45 75 60 110 100
Endocrinology 30 15 60 40 100 75 110 90 145 130
ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110
Gastroenterology 20 10 45 30 60 45 75 60 110 100
General Surgery 20 10 30 20 50 35 75 60 95 85
Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110
Infectious Diseases 30 15 60 40 100 75 110 90 145 130
Nephrology 30 15 45 30 80 60 90 75 125 110
Neurology 20 10 45 30 60 45 75 60 110 100
Neurosurgery 30 15 60 40 100 75 110 90 145 130
Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100
Oncology - Radiation/Radiation Oncology 30 15 60 40 100 75 110 90 145 130
Ophthalmology 20 10 30 20 50 35 75 60 95 85
Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85
Physiatry, Rehabilitative Medicine 30 15 45 30 80 60 90 75 125 110
Plastic Surgery 30 15 60 40 100 75 110 90 145 130
Podiatry 20 10 45 30 60 45 75 60 110 100
Psychiatry 20 10 45 30 60 45 75 60 110 100
Pulmonology 20 10 45 30 60 45 75 60 110 100
Rheumatology 30 15 60 40 100 75 110 90 145 130
Urology 20 10 45 30 60 45 75 60 110 100
Vascular Surgery 30 15 60 40 100 75 110 90 145 130
Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130
Acute Inpatient Hospitals 20 10 45 30 80 60 75 60 110 100
Cardiac Surgery Program 30 15 60 40 160 120 145 120 155 140
Cardiac Catheterization Services 30 15 60 40 160 120 145 120 155 140
Critical Care Services - Intensive Care Units (ICU) 20 10 45 30 160 120 145 120 155 140
Surgical Services (Outpatient or ASC) 20 10 45 30 80 60 75 60 110 100
Skilled Nursing Facilities 20 10 45 30 80 60 75 60 95 85
Diagnostic Radiology 20 10 45 30 80 60 75 60 110 100
Mammography 20 10 45 30 80 60 75 60 110 100
Physical Therapy 20 10 45 30 80 60 75 60 110 100
Occupational Therapy 20 10 45 30 80 60 75 60 110 100
Speech Therapy 20 10 45 30 80 60 75 60 110 100
Inpatient Psychiatric Facility Services 30 15 70 45 100 75 90 75 155 140
Outpatient Infusion/Chemotherapy 20 10 45 30 80 60 75 60 110 100

(3) By customization. When necessary due to utilization or supply patterns, CMS may set maximum time and distance standards for provider or facility types for specific counties by customization in accordance with the following rules:

(i) CMS maps provider location data from the Provider Supply file against its MA Medicare Sample Census (which provides MA enrollee population distribution data) or uses claims data to identify the distances beneficiaries travel according to the usual patterns of care for the county.

(ii) CMS identifies the distance at which 90 percent of the population would have access to at least one provider or facility in the applicable specialty type.

(iii) The resulting distance is then rounded up to the next multiple of 5, and a multiplier specific to the county designation is applied to determine the analogous maximum time.

(iv) Customization may only be used to increase the base time and distance standards specified in paragraph (d)(2) of this section and may not be used to decrease the base time and distance standards.

(4) Percentage of beneficiaries residing within maximum time and distance standards. MA plans must ensure both of the following:

(i) At least 85 percent of the beneficiaries residing in micro, rural, or CEAC counties have access to at least one provider/facility of each specialty type within the published time and distance standards.

(ii) At least 90 percent of the beneficiaries residing in large metro and metro counties have access to at least one provider/facility of each specialty type within the published time and distance standards.

(5) MA telehealth providers. An MA plan receives a 10 percentage point credit towards the percentage of beneficiaries residing within published time and distance standards for the applicable provider specialty type and county when the plan includes one or more telehealth providers that provide additional telehealth benefits, as defined in § 422.135, in its contracted networks for the following provider specialty types:

(i) Dermatology.

(ii) Psychiatry.

(iii) Cardiology.

(iv) Neurology.

(v) Otolaryngology.

(vi) Ophthalmology.

(vii) Allergy and Immunology.

(viii) Nephrology.

(ix) Primary Care.

(x) Gynecology/OB/GYN.

(xi) Endocrinology.

(xii) Infectious Diseases.

(6) State Certificate of Need (CON) laws. In a State with CON laws, or other state imposed anti-competitive restrictions that limit the number of providers or facilities in the State or a county in the State, CMS will award the MA organization a 10-percentage point credit towards the percentage of beneficiaries residing within published time and distance standards for affected providers and facilities in paragraph (b) of this section or, when necessary due to utilization or supply patterns, customize the base time and distance standards.

(e) Minimum number standard. CMS annually determines the minimum number standard for each provider and facility-specialty type as follows:

(1) General rule. The provider or facility must -

(i) Be within the maximum time and distance of at least one beneficiary in order to count towards the minimum number standard (requirement); and

(ii) Not be a telehealth-only provider.

(2) Minimum number requirement for provider and facility-specialty types. The minimum number for provider and facility-specialty types are as follows:

(i) For provider-specialty types described in paragraph (b)(1) of this section, CMS calculates the minimum number as specified in paragraph (e)(3) of this section.

(ii) For facility-specialty types described in paragraph (b)(2)(i) of this section, CMS calculates the minimum number as specified in paragraph (e)(3) of this section.

(iii) For facility-specialty types described in paragraphs (b)(2)(ii) through (xiv) of this section, the minimum requirement number is 1.

(3) Determination of the minimum number of for certain provider and facility-specialty types. For specialty types in paragraphs (b)(1) and (b)(2)(i) of this section, CMS multiplies the minimum ratio by the number of beneficiaries required to cover, divides the resulting product by 1,000, and rounds it up to the next whole number.

(i)

(A) The minimum ratio for provider specialty types represents the minimum number of providers per 1,000 beneficiaries.

(B) The minimum ratio for facility specialty type specified in paragraph (b)(2)(i) of this section (acute inpatient hospital) represents the minimum number of beds per 1,000 beneficiaries.

(C) The minimum ratios are as follows:

Table 2 to Paragraph (e)(3)(i)(C)

Minimum ratio Large metro Metro Micro Rural CEAC
Primary Care 1.67 1.67 1.42 1.42 1.42
Allergy and Immunology 0.05 0.05 0.04 0.04 0.04
Cardiology 0.27 0.27 0.23 0.23 0.23
Chiropractor 0.10 0.10 0.09 0.09 0.09
Dermatology 0.16 0.16 0.14 0.14 0.14
Endocrinology 0.04 0.04 0.03 0.03 0.03
ENT/Otolaryngology 0.06 0.06 0.05 0.05 0.05
Gastroenterology 0.12 0.12 0.10 0.10 0.10
General Surgery 0.28 0.28 0.24 0.24 0.24
Gynecology, OB/GYN 0.04 0.04 0.03 0.03 0.03
Infectious Diseases 0.03 0.03 0.03 0.03 0.03
Nephrology 0.09 0.09 0.08 0.08 0.08
Neurology 0.12 0.12 0.10 0.10 0.10
Neurosurgery 0.01 0.01 0.01 0.01 0.01
Oncology - Medical, Surgical 0.19 0.19 0.16 0.16 0.16
Oncology - Radiation/Radiation Oncology 0.06 0.06 0.05 0.05 0.05
Ophthalmology 0.24 0.24 0.20 0.20 0.20
Orthopedic Surgery 0.20 0.20 0.17 0.17 0.17
Physiatry, Rehabilitative Medicine 0.04 0.04 0.03 0.03 0.03
Plastic Surgery 0.01 0.01 0.01 0.01 0.01
Podiatry 0.19 0.19 0.16 0.16 0.16
Psychiatry 0.14 0.14 0.12 0.12 0.12
Pulmonology 0.13 0.13 0.11 0.11 0.11
Rheumatology 0.07 0.07 0.06 0.06 0.06
Urology 0.12 0.12 0.10 0.10 0.10
Vascular Surgery 0.02 0.02 0.02 0.02 0.02
Cardiothoracic Surgery 0.01 0.01 0.01 0.01 0.01
Acute Inpatient Hospitals 12.2 12.2 12.2 12.2 12.2

(ii)

(A) Number of beneficiaries required to cover.

(1) The number of beneficiaries required to cover is calculated by multiplying the 95th percentile base population ratio by the total number of Medicare beneficiaries residing in a county.

(2) CMS uses its MA State/County Penetration data to calculate the total number of beneficiaries residing in a county.

(B) 95th percentile base population ratio.

(1) The 95th percentile base population ratio is:

(i) Calculated annually for each county type and varies over time as MA market penetration and plan enrollment change across markets; and

(ii) Represents the proportion of Medicare beneficiaries enrolled in the 95th percentile MA plan (that is, 95 percent of plans have enrollment lower than this level).

(2) CMS calculates the 95th percentile base population ratio as follows:

(i) Uses its most recent List of PFFS Network Counties to exclude any private-fee-for-service (PFFS) plans in non-networked counties from the calculation at the county-type level.

(ii) Uses its most recent MA State/County Penetration data to determine the number of eligible Medicare beneficiaries in each county.

(iii) Uses its Monthly MA Enrollment By State/County/Contract data to determine enrollment at the contract ID and county level, including only enrollment in regional preferred provider organization (RPPO), local preferred provider organization (LPPO), HMO, HMO/provider sponsored organization (POS), healthcare prepayment plans under section 1833 of the Act, and network PFFS plan types.

(iv) Calculates penetration at the contract ID and county level by dividing the number of enrollees for a given contract ID and county by the number of eligible beneficiaries in that county.

(v) Groups counties by county designation to determine the 95th percentile of penetration among MA plans for each county type.

(f) Exception requests.

(1) An MA plan may request an exception to network adequacy criteria in paragraphs (b) through (e) of this section when both of the following occur:

(i) Certain providers or facilities are not available for the MA plan to meet the network adequacy criteria as shown in the Provider Supply file for the year for a given county and specialty type.

(ii) The MA plan has contracted with other providers and facilities that may be located beyond the limits in the time and distance criteria, but are currently available and accessible to most enrollees, consistent with the local pattern of care.

(2) In evaluating exception requests, CMS considers whether -

(i) The current access to providers and facilities is different from the HSD reference and Provider Supply files for the year;

(ii) There are other factors present, in accordance with § 422.112(a)(10)(v), that demonstrate that network access is consistent with or better than the original Medicare pattern of care; and

(iii) Approval of the exception is in the best interests of beneficiaries.

[85 FR 33904, June 2, 2020]