More Than Adequate

CMS recently unveiled a massive regulatory overhaul of Medicaid managed care requirements. Despite the fact that it’s being called a “mega-reg,” and taking some heat for its 1400+ page size, there’s certainly some interesting reading contained within, particularly for the telehealth community.

It’s all about network adequacy standards.

Health plans are regulated by states or CMS and measured based on their ability to demonstrate the adequacy of their in-network providers. How many are there? What’s the availability by specialty? Do consumers understand which providers are in-network? What does access look like in terms of wait times and distance? Answering these questions are the key to meeting the standard.

Historically, CMS adequacy measurements have not allowed for telehealth to meet these criteria. The telehealth world is still somewhat nascent, particularly in terms of CMS policy evolution, and inherently, the geographic mapping tools used to measure adequacy don’t really jibe with the “anywhere, anytime” nature of telehealth.

But, this so called “mega-reg” made the jump none the less, and urged states to consider telemedicine as they create their individual network adequacy standards for private Medicaid plans. This is a first and significant stake in the ground.

Combined with the National Association for Insurance Commissioners model state legislation, which if adopted would formally add telehealth as an acceptable component of meeting adequacy standards, states now have all the tools they need to better serve this high need population through technology.

If network adequacy is truly about ensuring access, transparency, availability, and timeliness, telehealth must be a part of the equation. CMS estimates that approximately 74million Americans will receive care through Medicaid this year. In order to provide sufficient provider access to these millions of patients, states must act and modernize their laws and regulations to take full advantage of the benefits of telehealth.

Kofi Jones is a government affairs specialist for American Well.