Response to Comments (60- and 30-day)

5_CMS Responses to 60_30 Day Comments_CY 2019.pdf

Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits (CMS-10237)

Response to Comments (60- and 30-day)

OMB: 0938-0935

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0935 can be found here:

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Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits as defined in Part 417 & 422 of 42 C.F. R.
CMS-10237, OMB 0938-0935
CMS Responses to 30 and 60-Day Comments on the Contract Year 2019 PART C - Medicare Advantage and 1876 Cost Plan Expansion Application
# Topic
Comment Text
CMS Response
1

HSD

We would support the removal of HSD submissions from the 2019
applications if CMS is able to provide clear and concrete information
regarding the timeline and process flow around what activities are due and
when they are due. However, until there is more predictability around the
CMS disposition of a network adequacy review and exception requests, we
recommend CMS continue to include network adequacy as part of the
application process. From a timing and resource perspective, conducting
the network adequacy review as part of the application process works well.
If the review is conducted later in the year, we have concerns with the
availability of time and plan resources because CMS has released no
details about how quickly a review would begin under a triggering event.

CMS Supply
File

We have observed discrepancies in the CMS Supply File, CMS online FFS
provider search tools and Quest Analytics software, especially for counties
with rural areas as those have resulted in unexpected disapprovals of
exception requests. The CMS Supply File in HPMS needs to have
information that is complete and consistent across all states. For example,
in the MN file some zip codes are missing. We also strongly urge CMS to
add the county code and/or county name to the file as well as release the
file more frequently throughout the year (last updated 4/27/17). CMS must
also be better at informing plans when a new Supply File is available in
HPMS.

CMS Action (Requirements/ Attachments/Burden
Change)
CMS appreciates the concern and would like to clarify that this is None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
simply a procedural change, and an organization’s first review
comment.
would occur after their application is approved, but prior to the
start of the first year in which the plan is offered. This gives new
plans and existing plans that are expanding their service area
additional time to secure a compliant network prior to the start of
the year. CMS will give careful thought to the compliance
approach when an initial applicant is found to have network
deficiencies or when an existing applicant applying for a service
area expansion has deficiencies. CMS is currently discussing
these details internally and will release guidance to the industry as
soon as possible.
Per the Medicare Advantage Network Adequacy Criteria
None. CMS has not revised any requirements,
Guidance, “given the dynamic nature of the market, the database attachments, or burden estimates as a result of this
comment.
may not be a complete depiction of the provider and facility
supply available in real-time. Additionally, the supply file is
limited to CMS data sources – organizations may have additional
data sources that identify providers/facilities not included in the
supply file used as the basis of CMS’s network adequacy criteria.
As a result, organizations should not rely solely on the supply file
when establishing networks, as additional providers and facilities
may be available. CMS uses the supply file when validating
information submitted on Exception Requests. Therefore, CMS
and its contractor may update the supply file periodically to reflect
updated provider and facility information and to capture
information associated with Exception Request submissions.”
This updated supply file and additional organization-provided
information is used in the acquisition of the Exception Requests.
As CMS makes the procedural change of removing network
reviews from the application process, it will look to improve
policies and procedures surrounding the supply file in order to
increase efficiency and data accuracy.

PRA Package
Type

60-Day

CMS Supply
File

We seek to understand how CMS is defining hospitals in the supply file as CMS recommends that the commenter submit their specific
having Critical Care Services - ICU services and where we can get the ICU questions to the CMS mailbox, located at: https://dmao.lmi.org.
bed counts. For example, Sanford Sheldon Medical Center hospital in
Spencer, IA is a hospital listed with services for Cardiac Catheterization
Services and Cardiac Surgery Program, but does not list the service for
Critical Care Services - ICU. Meanwhile a small town hospital like, Boone
County Hospital has Critical Care Services - ICU but that location only has
the typical hospital services of Acute Care Hospital, Diagnostic Radiology,
Mammography, Outpatient Infusion/Chemotherapy and Surgical Services.
We do not understand why a hospital that has Cardiac
Catheterization Services and a Cardiac Surgery Program is not listed with
ICU services on the supply file? Additionally, the CMS POS data file does
not have ICU bed count and we've seen that the identification of hospitals
with ICU on that file are not matching up with the supply file either. If
plans are required to provide bed counts for ICUs in the HSD facility
tables, we strongly urge CMS to include a definition for ICU population on
the supply file and provide a way for plans to access that information more
readily, either from the CMS POS or the supply file. We have historically
spent a lot of time on ICU and will continue to spend a lot of time if we
have to get ICU bed counts for hospitals that don't have a separate ICU.

HSD

CMS needs to issue the Exception Request form in Excel or Word format
that will allow plans to merge data and information already written,
organized and validated into the form. The current Exception Request PDF
fillable form is not user friendly and quite cumbersome to use. In the free
text sections, the font size is not readable as it shrinks when populated with
more than 100 characters. The only way we can view the information
entered in the fields is to copy/paste the text into a Word document. This is
an unnecessary and burdensome step for plans to have to take when
completing the exception form.

Thank you for your comment regarding CMS's exception request
policy. Consistent with the Supporting Statement, CMS removed
the Exception Request template from this information collection.
CMS will consider this comment as it develops the details
surrounding the information collection for CMS-10636, OMB
0938-New.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

PRA Package
Type

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

CMS Action (Requirements/ Attachments/Burden
Change)
The annual hours and resources needed to complete an entire network
CMS considered the feedback from organizations concerning the None. CMS has not revised any requirements,
submission for one contract (see Table 4 of the Supporting Statement - Part methodology for estimating the hour burden for submitting Health attachments, or burden estimates as a result of this
A, proposed Three-Year Network Adequacy) are grossly underestimated. Service Delivery (HSD) tables and Exception Requests to CMS, comment.
Based on our recent experience, we estimate three times what CMS lists
but after further review of its internal process, CMS is confident
for each activity required. Multiple staff are required, gaps need to be
in its estimation. There may be minimal burden associated with
researched, provider contracting may be needed, new reports run, staff
this change for those contracts that have never expanded beyond
analysis completed, etc. These activities account for many more hours than their original footprint or experienced an event that would trigger
what is represented in the table.
a full network review since they joined the program. In the case
of an SAE, CMS would review only the new service area’s
network (i.e., the expansion counties), and the entire network
review would occur at the contract’s three-year anniversary. With
regard to burden on the federal government, as CMS makes the
procedural change to move the network review out of the
application and into this three-year review, CMS has simply
shifted the annualized cost to the federal government from the
application PRA package to this new PRA package. Therefore,
no new cost to CMS has been added.

PRA Package
Type

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

Thank you for your comment regarding CMS's exception request None. CMS has not revised any requirements,
policy and network adequacy criteria. Consistent with the
attachments, or burden estimates as a result of this
Supporting Statement, CMS removed the Health Service Delivery comment.
tables and Exception Request template from this information
collection. CMS will consider this comment as it develops the
details surrounding the information collection for CMS-10636,
OMB 0938-New. CMS also recommends that the commenter
submit their specific question related to the automated review of
network adequacy in HPMS (via Quest) to the CMS mailbox,
located at: https://dmao.lmi.org.

60-Day

HSD

We are requesting CMS to clarify the process and timing for removing
CMS recommends that the commenter submit their specific
from the service area pending counties versus existing counties. Based on questions to the CMS mailbox, located at: https://dmao.lmi.org.
the April 11, 2017, CMS memo, the date to remove EXISTING counties
from the service area was Monday, June 5, 2017. However, CMS staff
informed us that the date to remove EXISTING counties was actually May
22, 2017 (the same time to remove pending counties from the service
area). The guidance does not align with the information provided by CMS
staff and caused much confusion due to lack of consistency.

HSD

During the 2018 application process, directions from CMS and Quest
Analytics about time standards enforcement were inconsistent. Both CMS'
Medicare Adv and Cost Plan Network Adequacy Criteria (1.18.17) and
CMS' HSD Reference File (1.10.2017) indicate time standards apply
across all specialty/county combinations. However, CMS approved without
explanation 2 specialty areas in a CEAC county where internal analyses
showed non-passing time results. Quest Analytics executives have directed
our plan to always run 'Distance Only' reports and stated that CMS only
applies time standards to Large Metro counties. We want to allocate
resources only where needed. We want to mirror CMS' use of Quest.
During the 2019 application process, will CMS always apply all the time
standards in CMS' HSD Reference File when testing HSD tables?

60-Day

HSD

We strongly support the application changes proposed in CMS-10237.
Network Adequacy is an operational area and, like other operational areas
for MAOs (ODAG, CDAG, etc.), it should be reviewed in its proper
operational context and time frame. The goal of tying a Plan's network to
its proposed SAE expansion to assure a Plan can properly provide for its
members on day one is a good one. But there are better ways to test this,
especially since the application time frame and data used to support an
application can be up to one year out of date as of day one of a Plan's go
live into its new area.
We greatly appreciates CMS’ efforts to streamline the service area
expansion process by separating network adequacy reviews from the
application process. We understand the need for CMS to conduct oversight
monitoring to ensure that MA plans continue to maintain adequate
networks. As such, we support the proposal to conduct three year network
adequacy reviews and support the proposal to remove the Health Service
Delivery (HSD) tables from the MA application. We believe that these
changes will reduce burden on plans as well as CMS staff, while
establishing a transparent, predictable process for comprehensive network
reviews.
Exceptions: We respectfully request CMS reconsider the requirement that
all network adequacy exceptions be re-reviewed annually. Exceptions are
often the result of a lack of provider specialties in a given geographic area,
which presents a challenge to Medicare broadly. Thus we recommend
CMS retain previously approved exception requests in between the three
year review cycle as long as there were no negative changes to the network
from the approved contract year.
Provider-Specific Plans (PSPs): CMS did not address how review of PSP
networks will be handled. We recommend they be included as part of the
three year review cycle. If CMS continues to review PSP networks
annually, we strongly suggest that CMS limit their review to the affected
service areas.

PRA Package
Type

CMS appreciates the positive feedback and support. CMS will
strive for appropriate, equitable implementation of this
information collection.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

CMS appreciates the positive feedback and support. CMS will
strive for appropriate, equitable implementation of this
information collection.

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

Thank you for your comment regarding the information collection None. CMS has not revised any requirements,
for CMS-10636, OMB 0938-New. CMS will consider this
attachments, or burden estimates as a result of this
comment as it develops the details related to the three year
comment.
network review cycle.

60-Day

Service Area

SMAC

I-SNP

CMS Action (Requirements/ Attachments/Burden
Change)
We recommend CMS transition the Orthotics and Prosthetics specialty to CMS agrees with this comment. Recent analysis of claims data
Requirements. CMS modified attestation 3.8.6 as
monitoring through an attestation.
and industry trends demonstrates that Medicare Advantage (MA) follows: Applicant agrees that it will provide all
Similar to Home Health and Durable Medical Equipment, care provided by enrollees often receive Orthotics and Prosthetics services in the
medically necessary durable medical equipment,
the Orthotics and Prosthetics specialty is not bound to a facility or office
prosthetics, orthotics, and supplies (DMEPOS),
home or a hospital. Therefore, CMS does not believe time and
location, as services are provided at a patient's home or local hospital or
including access to providers qualified to fit these
distance criteria standards are unrealistic for this specialty type.
clinic. For this reason, time and distance requirements are not appropriate While CMS removed the health service delivery tables from this devices, to its Medicare enrollees in full agreement
application (see Supporting Statement), CMS does include several with Chapter 4 of the MMCM.
for this specialty.
attestations under the Service Area section of the application.
Other specialties for which the time and distance requirements are not
CMS agrees with the recommendation to include an attestation for Attachment and Burden. CMS has not revised any
appropriate are currently monitored through attestation.
orthotics and prothestics coverage in the attestation, consistent
attachments or burden estimates as a result of this
To operationalize this recommendation, we propose the addition of the
with the attestations included for home health, transplant
comment.
following language to 3.8.6: "Applicant agrees that it will provide all
medically necessary durable medical equipment, prosthetics, orthotics, and facilities, and durable medical equipment.
supplies (DMEPOS), including access to providers qualified to fit these
devices, to its Medicare enrollees in full agreement with Chapter 4 of the
MMCM."
The proposed modification will ensure that prosthetics and orthotics are
included in the application process as an attestation, similar to the other
monitored programs and services.
The SMAC and FIDE submission dates are listed as July 5, 2018.
CMS agrees with this comment. SMAC and FIDE submissions are Requirements. CMS modified section 5.4 of the
Previously the SMAC and FIDE submissions were due the first Monday in due on the first Monday in July, or on July 2, 2018. CMS
application as follows: The SMAC documents will be
July which would be July 2, 2018. Could CMS please clarify if this
modified the instructions under 5.4 of the application based on
due by July 2, 2018.
changed?
this comment.
Attachment and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment.
The intent of the language in Attestation No. 1 (Section 5.5 "I-SNP:
CMS agrees with this comment. CMS modified 5.5 of the
Requirements. CMS modified one attestation for I-SNP
Attestations and Uploads") is somewhat confusing and appears to conflict application for I-SNP Individuals Residing ONLY in Institutions Individuals Residing ONLY in Institutions under
with other guidance regarding requirements of I-SNPs to be under contract consistent with the commentor's suggestion.
section 5.5 of the application as follows: Applicant will
with and operate LTC facilities. The attestation states: "Applicant will only
only enroll institutionalized individuals residing in a
enroll institutionalized individuals residing in a long-term care (LTC)
long-term care (LTC) facility under contract with or
facility under contract with and owned by the SNP, or if no ownership, a
owned and operated by the SNP.
contract exists between the I-SNP and LTC." We propose that this
Attachments and Burden. CMS has not revised any
attestation be modified as follows:
attachments or burden estimates as a result of this
"Applicant will only enroll institutionalized individuals residing in a longcomment.
term care (LTC) facility under contract with or owned and operated by the
SNP."

PRA Package
Type

60-Day

I-SNP

MSA

Our understanding is that I-SNPs may, but are not required, to contract
with Assisted living facilities (ALF). Question 4.a. of the I-SNP
Individuals Residing in Both Institutions and the Community Upload
Document reads: "Applicant is contracting with assisted living facilities or
other residential facilities." We believe this question should be re-worded
to be clear that I-SNP applicants that intend to serve individuals that reside
in both institutions and the community have the option to contract with
ALFs, and suggest that the question be modified as follows:
"For institutional equivalent individuals residing in the community,
provide a list of applicable assisted living facilities or other residential
facilities, e.g., continuing care communities. (Note use of ALF or other
residential facilities is optional for I-SNPs that serve institutional
equivalent individuals in the community.)"
Compliance Crosswalk: On page 24 of the 2019 Part C Application,
section 3.5.C., there is a request to complete and upload the crosswalk for
Part C compliance plan document. No crosswalk template is provided in
the 2019 (or CY2018) application information.
Inform Health recommends that CMS either eliminate the crosswalk
requirement or provide the desired template for submission.

CMS agrees with this comment. CMS modified 5.13.3 of the
application consistent with the commentor's suggestion.

Thank you for your comment. Under attestation 3.5.1, CMS
requires that organizations respond yes or no to the following
attestation:
Applicant will adhere to all compliance regulations in
accordance with but not limited to 42 CFR 422.503(b)(4)(vi).

CMS Action (Requirements/ Attachments/Burden PRA Package
Type
Change)
Requirements. CMS modified one attestation in the
60-Day
upload document under section 5.13.3 of the
application as follows: 4.a. For institutional equivalent
individuals residing in the community, provide a list of
applicable assisted living facilities or other residential
facilities, e.g., continuing care communities. (Note:
The use of Assisted Living Facilities or other
residential facilities is optional for I-SNPs that serve
institutional equivalent individuals in the community.)
Attachments and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment.
Requirements. CMS will only require that MA-only
60-Day
non-network PFFS and MSA plans complete the
compliance attestation under 3.5.1. CMS will no longer
require uploads of the compliance plan and supporting
matrix documents. CMS deleted 3.5.B and 3.5.C from
the application.

Under 3.5.B and 3.5.C, CMS required that MA-only non-network Burden. CMS anticipates a reduction of two hours
(Private Fee-for-Service and Medical Savings Account) applicants based on this change for the MA-only non-network
upload a compliance plan and compliance plan crosswalk in
MSA and PFFS intitial and SAE applications only.
addition to the attestation.
Attachments. CMS modified the Summary Statement
Upon review, CMS will remove both 3.5.B and 3.5.C from the
to account for the burden reduction associated with
application requirements. CMS believes that the response to
this removal.
attestation 3.5.1 provides the necessary assurances for CMS to
determine the MA-only non-network applicants adherence to
CMS's compliance requirements for the purpose of 42 CFR
Subpart K.

MSA

CMS Action (Requirements/ Attachments/Burden PRA Package
Type
Change)
Banking Contract: On page 43 of the 2019 Part C Application, sections
Thank you for your comment. Under attestation 3.25.6, CMS
Requirements. CMS modified attestation C.25.6 as
60-Day
3.25.6 and 3.25.B., the application requires uploading an executed banking requires that MSA applicants respond yes or no to the following follows: Applicant will establish a relationship with a
contract. Section 3.25.B. is very clear on the required CMS direct and/or attestation:
banking partner that meets the Internal Revenue
delegated contracting requirements are included in the contract, but does
Service (IRS) requirements (as a bank, insurance
Applicant will establish a relationship with a banking partner
not provide any additional guidance on banking contract requirements.
company or other entity) as set out in Treasury Reg.
that meets the Internal Revenue Service (IRS) requirements (as a Secs. 1.408-2(e)(2) through (e)(5). Applicant will
Inform Health recommends that CMS state any specific MSA banking
requirements outside of those currently articulated in section 3.25.B. that bank, insurance company or other entity) as set out in Treasury establish policies and procedures with its banking
Reg. Secs. 1.408-2(e)(2) through (e)(5). Applicant will establish partner that include the services provided by the
need to be included in the MSA banking executed contract.
Inform Health also recommends that CMS offer a standard MSA banking policies and procedures with its banking partner that include the banking partner, including how members access funds,
contract template in the 2019 Part C Application to ensure all requirements services provided by the banking partner, including how
how spending is tracked and applied to the deductible,
are clear and included by MSA applicants.
members access funds, how spending is tracked and applied to
and how claims are processed.
the deductible, and how claims are processed.
Burden.
Under 3.25.B, CMS required that MSA applications also upload
the executed banking contract "for review by CMS to ensure that
ALL CMS direct and/or any delegated contracting requirements
are included in the contract.

CMS also removed the requirement for MSAs to
upload an executed banking contract. In removing this
requirement, CMS renumbered the remaining MSAonly upload documents.

Upon review, CMS will remove both 3.25.B from the application
requirements. CMS believes that the response to attestation 3.25.6
provides the necessary assurances for CMS to determine the MSA
applicant's adherence to CMS's banking requirements for the
purpose of 42 CFR Subpart K.

Attachments and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment. CMS did not include a burden estimate for
the banking contract upload in the initial Supporting
Statement. CMS notes that MSA banking
contract/reporting requirements are discussed in the
information collection under OMB control number
0938-0753, CMS-R-267.

HSD

Removal of Health Services Delivery (HSD) Tables. CMS is proposing to CMS appreciates the positive feedback and support. CMS will
remove the submission and review of the provider and facility Health
strive for appropriate, equitable implementation of this
Services Delivery (HSD) tables and related exceptions requests from the
information collection.
MA application process beginning with the CY 2019 application cycle.
Under the proposal, CMS would no longer evaluate and review MA
provider and facility networks with the application, and would instead
create a separate and distinct process to conduct network reviews as part of
contract operations (i.e., an operational function). CMS has published a
related information collection entitled, “Three-Year Network Adequacy
Review for Medicare Advantage Organizations” that proposes to establish
this new operational function. The proposed approach would require
organizations to upload HSD tables to the HPMS Network Management
Module (NMM) for any contract that has not had an entire network review
performed by the agency in the previous three-years of contract operation.
HCSC has expressed general support for the Three-Year Network
Adequacy Review proposal, which we believe could permit CMS to take a
more balanced and uniform approach to evaluating and determining MA
organization compliance with network adequacy requirements as all
contracts will be subject to the three-year review cycle. This approach also
may better position CMS to determine whether there is potential for
beneficiary harm related to undetected network deficiencies in a manner
that is consistent across all, rather than a subset of contracts.

HSD

Transparency in the Development Process. As CMS continues to consider CMS appreciates the positive feedback and support. CMS will
removing the HSD review and submission process from the MA
strive for appropriate, equitable implementation of this
application, and further refines the new proposed operational approach
information collection.
(e.g., identifying needed systems and other modifications), HCSC
recommends that the agency work in close and ongoing collaboration with
MA organizations in a transparent manner. These steps will allow CMS to
benefit from the range of MA organization practical experience and
knowledge, and ensure any operational issues or considerations are
identified as early as possible in the development process and well in
advance of implementation. In addition, given the increased scale and
scope of the proposed approach in comparison to the current review
process, it will be important for CMS to take a flexible approach to initial
implementation of the new process to accommodate the significant system,
administrative, and timing resources that will be required on the part of the
agency and plans.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

PRA Package
Type

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

HSD

CMS Action (Requirements/ Attachments/Burden
Change)
Implementation Timing. The CMS Supporting Statement indicates that the Thank you for your comment regarding the information collection None. CMS has not revised any requirements,
agency’s goal is to remove the HSD submission and review process from for CMS-10636, OMB 0938-New. CMS is currently discussing a attachments, or burden estimates as a result of this
the MA applications beginning with the CY 2019 applications. However, proposed timeline for reviews internally and will release guidance comment.
the timing of when CMS envisions the initial 3-year network reviews
to the industry as soon as review timeframes and activities are
would begin under a new process is unclear. For clarity, we recommend
defined.
that CMS confirm when the agency will begin the network adequacy
reviews under the revised approach, as well as the timing of when and how
impacted organizations will be notified of requests to upload HSD tables in
the initial and subsequent years of implementation. As a practical
consideration, we encourage CMS to establish a timeline that avoids
implementation early in the year, and to ensure that the sample beneficiary
file against which an organization’s networks must be compared is
available well in advance of that timing.
Exception Requests. HSCS believes it is important that MA organizations Thank you for your comment regarding CMS's exception request None. CMS has not revised any requirements,
policy. Consistent with the Supporting Statement, CMS removed attachments, or burden estimates as a result of this
have the ability to submit requests when an exception to the current
network adequacy criteria is warranted, especially given the continuously the Exception Request template from this information collection. comment.
CMS will consider this comment as it develops the details
evolving patterns of care in certain service areas, and we appreciate that
surrounding the information collection for CMS-10636, OMB
CMS is proposing to maintain this process under the revised network
0938-New.
adequacy review approach. We recommend that CMS also consider
implementing a process to make available to all organizations in a given
service area, information regarding all approved Exception Requests for
certain provider types in the service area in an effort to increase
transparency and consistency in the review process.

PRA Package
Type

60-Day

HSD

Significant Network Changes. CMS requires MA organizations to notify
the agency of any no-cause provider termination that the organization
deems to be a “significant” change to the provider network, at least 90days prior to the effective date of the change (See
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/mc86c04.pdf). The agency
believes that MA organizations “may be in the best position to determine
whether or not a provider termination without cause is significant” and
expects organizations to take a conservative approach in making such
determinations and notifying CMS accordingly. The agency notes that an
organization that does not notify CMS of network changes that are
ultimately determined by CMS to be significant will be subject to
appropriate compliance actions. CMS guidance broadly defines
“significant” changes as those changes to provider networks that go
beyond individual or limited provider terminations that occur during the
routine course of plan operations and affect, or have the potential to affect,
a large number of enrollees. Consistent with previous comments we have
submitted on this topic, we recommend that CMS further clarify and refine
the definition of “significant” network changes, for example, by providing
guidelines and/or criteria organizations may use to make determinations.
We believe this step would promote a common understanding across MA
organizations of the agency’s expectations, as well as support compliance
with CMS’ requirements.
Changes to Application. We note that along with the draft application,
CMS issued a document that provides a high-level summary/crosswalk of
changes the agency is proposing. We appreciate that CMS has made the
document available and recommend that the agency consider providing a
similar crosswalk when the final versions of the applications are released
to help applicants more efficiently identify and navigate the year-over-year
application changes.

CMS recommends that the commenter submit their specific
questions to the CMS mailbox, located at: https://dpap.lmi.org.

Thank you for your feedback regarding the high-level
summary/crosswalk of changes proposed through this information
collection. CMS has modified this summary of changes document
to include the sections impacted during the 60-day comment
process.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

60-Day

Attachments. CMS revised the CY 2019 High Level
60-Day
Summary of Change or Crosswalk of Changes for PRA
Package CMS 10237: Part C - MA and 1876 Cost Plan
Expansion Application document in response to this
comment.
Requirements and Burden. CMS has not revised any
requirements or burden estimates as a result of this
comment.

PRA Package
Type

HSD

In the Supporting Statement, CMS indicates that the agency has removed
the Health Service Delivery (HSD) provider table upload and will no
longer evaluate HSD tables with applications. We support CMS’s
proposal to remove network reviews, including exception requests, from
the application process. However, we continue to emphasize that the
current exceptions criteria and process should be updated to account for
the latest, most innovative MA care delivery models. The use of highvalue provider networks and integrated care delivery systems and offering
of personalized care access options, including telehealth services, are just
some examples of current MA plan efforts to bring high quality and
coordinated care to Medicare beneficiaries. As such, we believe that the
exceptions guidelines should consider new models of care delivery. We
therefore continue to recommend that CMS work with health plans to
improve the exceptions criteria and process to reflect the innovations that
plans are using to improve the quality and delivery of care.

HSD

MVP Health Care supports the recommendation to remove the HSD
submission from the Expansion Application. As stated we are now
submitting this data on a routine basis. Thank you for the suggestion to
decrease our administrative burden.

CMS Action (Requirements/ Attachments/Burden
Change)
CMS appreciates the positive feedback and support. CMS is
None. CMS has not revised any requirements,
currently updating its network adequacy guidance and will release attachments, or burden estimates as a result of this
any updated guidance to industry. CMS will strive for appropriate, comment.
equitable implementation of this information collection.

PRA Package
Type

CMS appreciates the positive feedback and support. CMS will
strive for appropriate, equitable implementation of this
information collection.

30-Day

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

30-Day

File Type	application/pdf
Author	Stacy DAVIS
File Modified	2018-01-29
File Created	2018-01-29