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CMS Rule Expands States’ Flexibilities for Network Adequacy and Telehealth

By January 4, 2021No Comments

In November the Centers for Medicare and Medicaid Services (CMS) released its 2020 Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final Rule. CMS states that its goal with the rule was to reduce federal regulatory barriers, support flexibility and promote transparency and innovation when states develop and implement managed care programs for Medicaid and CHIP.   The rule addresses telehealth specifically in relation to how telehealth visits should be counted towards meeting a managed care plan’s network adequacy requirement.  CMS states in the rule the following:


We defer to each state to determine the criteria to be applied to telehealth providers and how such providers would be taken into account when evaluating network adequacy of the state’s Medicaid managed care plans. Section 438.68(b) does not set criteria of this nature that states must use. Under § 438.68(c)(1)(ix), states must consider the availability and use of telemedicine when developing their network adequacy standards. If states elect to include telehealth providers in their network adequacy analysis, we believe that the states will establish criteria that appropriately reflect the unique nature of telehealth, as well as the availability and practical usage of telehealth in their state.

CMS also states in its press release on the rule that the adjustments it made to the minimum standards states must use in developing network adequacy requirements will support state facilitation for telehealth options.  Specifically, the rule removes the requirement for states to set time and distance standards and adds a more flexible requirement that states set a quantitative network adequacy standard for network adequacy.  It also broadens its definition of provider types, and allows states to have authority to define a ‘specialist’.  They do note however that they expect states to apply network adequacy standards to all providers types and specialties necessary to ensure that all services covered under the contract are available and accessible to all enrollees in a timely manner.  For more information on the final rule, see CMS’ factsheet or read the rule in its entirety.


CCHP Animated Video on Telehealth Reimbursement Basics
CCHP knows that telehealth policy is complicated, especially when it comes to the way that reimbursement works in the United States.  To help, we’ve developed an animated video to help those new to telehealth policy understand how telehealth policy works in the US, and the role of telehealth COVID-19 waiver and exceptions during the public health emergency.  If you want a crash course in telehealth reimbursement policy in just 13 minutes, this is the place to start!  See the video HERE.