Sec. 123. Network adequacy

472 words·~2 min read·/bill/116/hr/2452/ih/section-123

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Section 1852(d) of the Social Security Act ( 42 U.S.C. 1395w–22(d) ) is amended by adding at the end the following: Beginning in plan year 2019, notwithstanding any other provision of law, the following shall apply: When establishing a plan network, a Medicare Advantage organization offering an MA plan shall, among other factors determined by the Secretary, consider the following: The anticipated enrollment in the plan. The expected types of services provided and utilization of services by enrollees under the plan.

The number and types of providers needed to provide such services. The number of network providers who are not accepting new patients. The location of providers and enrollees, taking into account geographic disbursement. The full-time equivalent availability of a provider to provide such services. A Medicare Advantage organization offering an MA plan shall ensure that providers are able to provide services in a timely manner, as defined by the Secretary, under the plan. In applying the network access adequacy standards pursuant to paragraph (1), the Secretary shall seek input from patient advocacy groups, providers of services and suppliers, and MA plans under this part.

Each plan year, a Medicare Advantage organization shall certify to the Secretary, with respect to each MA plan offered by the organization, that the providers, including specialists and subspecialists, in the plan network are able to provide the services required under the organization’s contract with the Secretary under section 1857 with respect to the offering of such plan and to meet the needs of the enrollees within the plan service area during the year. Each plan year, a Medicare Advantage organization shall report to the Secretary, and make public the following with respect to each MA plan offered by the organization:

The average wait time for primary and specialty care for enrollees under the plan. The utilization of out-of-network providers under the plan. The average annual spending per patient for primary and specialty care for enrollees under the plan. In advance of the annual, coordinated election period under section 1851(e)(3), a Medicare Advantage organization shall certify to the Secretary the accuracy of provider directories for each plan offered by the organization. The Secretary shall ensure that the network of each MA plan offered by a Medicare Advantage organization meets the network adequacy guidelines established under this paragraph and under section 422.112(a)(4) of title 42, Code of Federal Regulations (or any successor regulation to such section) at least once every 3 years or when a material change in network occurs.

The Secretary shall have the authority to stop any further enrollment in a Medicare Advantage plan if there is a pattern of excessive violations of this paragraph. . Section 1857(g)(1)(K) of the Social Security Act ( 42 U.S.C. 1395w–27(g)(1)(K) ), as added by section 2(b), is amended by striking or 1852(d)(8) and inserting , 1852(d)(8), or 1852(d)(9) .

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42 USC 1395w–22(d)
42 USC 1395w–27(g)(1)(K)

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Sec. 123

Network adequacy

Cite42 USC 1395w–22(d)

Cite42 USC 1395w–27(g)(1)(K)

Cites 2Cited by 0 across 0 sources