Crosswalk: Justification Template

4.11 CY 2018 Partial County Justification Template
Instructions: MA applicantsOrganizations requesting service areas that include one or more
partial counties must upload a completed Partial County Justification into HPMSwith the MA
Application.
Complete and upload a Partial County Justification form for each partial county in your current
and proposed service area. This form template is appropriate for organizations (1) offering a
current partial county, (2) entering into a new partial county, or (32) expanding a current partial
county by one or more zip codes when the resulting service area will continue to be a partial
county. In this scenario, the Justification pertains to the proposed zip codes versus the zip codes
already approved by CMS. This template applies for any organization that has a partial county
as part of its service area. Organizations must complete and upload a Partial County Justification
for any active/existing partial county or pending/expanding partial county.
MA applicantsOrganizations expanding from a partial county to a full county do NOT need to
submit a Partial County Justification.
Beginning with the CY2016 applications, HPMS will automatically assess the contracted
provider and facility networks against the current CMS network adequacy criteria. If the ACC
report shows that an organization provider or facility fails the network criteria for a given
county/specialty, then the applicantorganization must submit an Exception Request using the
same process available tofor full-county applicantsservice areas.
CMS has revised its partial county guidance to eliminate the use of the inability to establish
economically viable contracts as a partial county justification.
NOTE: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
Using just a few sentences, briefly describe why you are proposing a partial county service area.
SECTION II: Partial County Requirements
The Medicare Managed Care Manual Chapter 4, Section 140.3Medicare Advantage Network
Adequacy Criteria Guidance provides guidance on partial county requirements. The following
questions pertain to those requirements.; refer to Section 140.3 when responding to them.
Explain how and submit documentation to show that the partial county meets all three of the
following criteria:
1. Necessary – It is not possible to establish a network of providers to serve the entire
county.
Describe the evidence that you are providing to substantiate the above statement that it is
not possible to establish a network to serve the entire county and (if applicable) attach it
to this form.:
2. Non-discriminatory – You must be able to substantiate both ofdemonstrate
the following statements:
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The anticipated enrollee health care cost in the portion of the county you are
proposing to serve is comparable to the excluded portion of the county.
Describe the evidence that you are providing to substantiate the above statement
and (if applicable) attach it to this form.

•

The racial and economic composition of the population in the portion of the county
you are proposing to serve is comparable to the excluded portion of the county.
Describe the evidence that you are providing to substantiate the above statement
and (if applicable) attach it to this form.

The racial and economic composition of the population in the portion of the county you are
proposing is comparable to the excluded portion of the county.

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Using U.S. census data (or data from another comparable source), compare the racial and
economic composition of the included and excluded portions of the proposed county service area.
•

The anticipated health care costs of the portion of the county you are proposing to serve is
similar to the area of the county that will be excluded from the service area.
Describe the evidence that you are providing to substantiate the above statement and (if
applicable) attach it to this form:
3. In the bBest iInterests of the bBeneficiaries – The partial county must be in the best
interests of the beneficiaries who are in the pending service area.
Describe the evidence that you are providing to substantiate the above statement and (if
applicable) attach it to this form.:
SECTION III: Geography
Describe the geographic areas for the county, both inside and outside the proposed service area,
including the major population centers, transportation arteries, significant topographic features
(e.g., mountains, water barriers, large national parklakes, mountain ranges, etc.), and any other
geographic factors that affected your service area designation.

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