CMS Pub. 100-16, ch. 9, § 40.3

Coordinated Care Plans

(Rev. 111, 05-03-13, Effective: 05-03-13, Implementation: 05-03-13)

To enable employers/unions to offer coordinated care plans to all their Medicare-eligible

members wherever they reside, CMS has expanded the waiver of service area requirements for

MAOs offering local coordinated care plans (e.g., local PPOs and HMOs) as described in this

section. An MAO offering a coordinated care plan in a given service area (i.e., State) can extend

coverage to an employer/union sponsor’s beneficiaries residing outside of that service area when

the MAO, either itself or through partnerships (i.e., arrangements) with other MAOs, is able to

meet CMS provider network adequacy requirements and provide consistent benefits to those

beneficiaries.

This waiver is made available in recognition that an MAO offering a local coordinated care “800

series” plan has limited flexibility in designing an expanded service area outside a State in which

it is unable to secure contracts with an adequate number of network providers to satisfy CMS’

MA coordinated care network adequacy requirements that would otherwise apply. MAOs

offering “800 series” local coordinated care plans that desire to offer expanded service areas

(e.g., national service areas) must request an expanded “800 series” service area in accordance

with CMS requirements and meet the following conditions:

(1) The MAO must be able to meet CMS’ MA coordinated care network adequacy

requirements for at 51% of a particular employer or union group’s beneficiaries enrolled

in the “800 series” coordinated care plan. In those instances where the MAO cannot meet

this requirement for a particular employer or union group’s beneficiaries, CMS will

require information, including MA network adequacy information for the particular

employer or union group, to be submitted for review and approval by CMS;

(2) All of an employer or union group’s beneficiaries, including those beneficiaries that do

not have access to contracted MA network providers, must receive the same covered

benefits at the preferred in-network cost sharing for all covered benefits offered by the

coordinated care plan;

(3) The MAO must provide payment to non-contract providers in accordance with the

requirements of “The Act” (i.e., the MAO must provide “payment in an amount so that –

(i) the sum of such payment amount and any cost sharing provided under the plan is equal

to at least (ii) the total dollar amount of payment for such items and services as would

otherwise be authorized under parts A and B (including any balance billing under such

parts [emphasis added])”). Note that, unlike private fee-for-service MA plans, MAOs

offering local coordinated care plans may pay more than the required above-mentioned

statutory amounts to any particular non-contract provider. Please note that hospitals and

other institutional providers with Original Medicare fee-for-service provider agreements

that place certain restrictions on treating any Medicare beneficiaries may be subject to

having those agreements terminated by CMS. (See also 42 CFR 422.214; and 42 CFR

489.53(a)(2).)

(4) The MAO must take whatever steps are necessary to ensure that beneficiaries residing in

areas where the MAO is unable to secure contracts with an adequate number of a specific

type of provider(s) to satisfy CMS’ MA network adequacy requirements will have access

to providers. This may include providing assistance to these beneficiaries in locating

providers and/or utilizing its ability, as outlined above, to pay non-contract providers

more than the statutory minimum required in section 1852(a)(2)(A) of the Social Security

Act;

(5) In addition to assisting enrollees residing in non-network areas of the local coordinated

care plan (i.e., areas in which the MAO is unable to satisfy CMS’ network adequacy

requirements) in finding providers who will furnish services, the MAO must also

establish a program to specifically assist these enrollees in the coordination of their health

care services. Areas that should be addressed in its coordination plan for its non-network

enrollees are discussed in Chapter 4 of this manual;

(6) In order to minimize any adverse effects on beneficiaries residing in areas where the

MAO is unable to satisfy CMS’ MA network adequacy requirements, the MAO also must

have in place an effective communication plan with employer groups prior to

transitioning these employer group beneficiaries to the local coordinated care plan. This

must include the following key communications:

(a) Ensure employer sponsors and their beneficiaries understand how the plan will

work for those enrollees residing in areas where MA network providers are not

available, including that non-contract providers are generally not required to accept

the plan and furnish services;

(b) Ensure the MAO has a targeted communication strategy and provides information

and assistance to beneficiaries affected by lack of access to network providers (e.g.,

whom to contact if they have difficulties locating a provider that will furnish

services, etc);

(c) Conduct targeted education and outreach to the current providers of beneficiaries

affected by lack of access to network providers prior to transitioning the group to

the local coordinated care plan. This may include explaining how the local

coordinated care employer group product works, how claims are submitted, etc.;

and

(d) Assure all non-contract providers that they will receive prompt and accurate

payment.

(7) In addition, MAOs offering “800” series local coordinated care plans that desire

expanded services areas (e.g., a national service area) must request an expanded service

area in accordance with CMS requirements to ensure their service area is properly

defined in HPMS and must bid accordingly.