CMS-10636 Partial County Justification Template

Partial County Justification Template
Instructions: Organizations requesting service areas that include one or more partial counties
must upload a completed Partial County Justification template into HPMS for each partial county
in the organization’s current and proposed service area.
This template is appropriate for organizations (1) offering a current partial county, (2) entering
into a new partial county, or (3) expanding a current partial county by one or more zip codes
when the resulting service area will continue to be a partial county. 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.
Organizations expanding from a partial county to a full county do NOT need to submit a Partial
County Justification.
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 fails the criteria
for a given county/specialty, then the organization must submit an exception request using the
same process available for full-county service areas.
NOTE: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
The organization must provide CMS short description (two to three sentences) regarding why
they are proposing a partial county service area.
SECTION II: Partial County Requirements
The Medicare Advantage Network Adequacy Criteria Guidance provides guidance on partial
county requirements. The following questions pertain to those requirements.
The organization must 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 provided to substantiate the above statement and (if applicable)
attach it to the template.
2. Non-discriminatory – The organization also must be able to demonstrate the following:
•

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 provided to substantiate the above statement and (if
applicable) attach it to the template.

•

The racial and economic composition of the population in the portion of the
county the organization is proposing to cover is comparable to the excluded
portion of the county.
Describe the evidence provided to substantiate the above statement and (if
applicable) attach it to the template.

3. In the Best Interests of the Beneficiaries – The partial county must be in the best
interests of the beneficiaries who are in the pending service area. Organizations must
describe the evidence substantiating the above statement and (if applicable) attach it to
the template.
SECTION III: Geography
The organization must 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 park), and any other
geographic factors that affected the service area designation.
PRA Disclosure Statement This form is required by CMS to determine MAO compliance with network
adequacy criteria under §422.116 and requirements under §§417.414, 417.416, 422.112(a)(1)(i), and
422.114(a)(3)(ii). The form is required when CMS performs a contract-level network review. Use of this form is
considered mandatory under the authority of Section 1852(d)(1) of the Social Security Act which permits an
MAO to select the providers from which an enrollee may receive covered benefits. Under the Privacy Act of
1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1346 (Expires: XX/XX/20XX). The time required to complete this information collection is
estimated to average 37 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.