The document discusses changes to the 2014 CMS application including county classification changes, specialty code changes, beneficiary count changes, and time and distance requirements. It outlines the different county types used in the adequacy methodology and shows the new time and distance standards for providers and facilities by county type. The presentation aims to help providers get a solid grip on reference file changes and network adequacy criteria for the 2014 CMS application.

1. Getting a SOLID GRIP on the
2014 CMS APPLICATION
P R O V I D I N G P O W E R F U L S O L U T I O N S

2. PRESENTERS
What’s your Quest? Let us guide the way.
Account Managers
Darren Huff, Eastern Region
Darren.Huff@QuestAnalytics.com
Michelle LeCloux, Western Region
Michelle.LeCloux@QuestAnalytics.com
Contact us at:
920.739.4552

3. AGENDA
Reference File Changes
 Counties Changing Classifications
 Specialty Code Changes
 Beneficiary Changes
 Minimum Provider Count Changes
 Time & Distance Changes
Medicare & Dual Demonstrations
 Network Adequacy criteria
 MA table uploads
The Quest Analytics Suite™
 Key enhancements
 Answers to the test
 Automate and simplify
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4. Reference File CHANGES
Quest Analytics

5. COUNTY CLASS Changes
Tighter Standards Relaxed Standard
County SSA County Name State County Class for 2014 County Class from 2013
03130 Yuma AZ Metro Micro
10380 Liberty FL CEAC Rural
11020 Baker GA CEAC Rural
15580 Orange IN Micro Rural
19390 Rapides LA Metro Micro
25120 Clay MS Rural Micro
33380 Montgomery NY Micro Metro
44210 Dickson TN Metro Micro
45010 Andrews TX Rural CEAC
45040 Archer TX CEAC Rural
45880 Runnels TX Rural CEAC
45980 Yoakum TX Rural CEAC
49241 Danville City VA Micro Metro
52400 Monroe WI Micro Rural

6. SPECIALTY CODE Changes
CMS Code Specialty CHANGE
024 Oral & Maxillofacial Surgery ELIMINATED
009 Cardiac Surgery COMBINED WITH 009
032 Thoracic Surgery COMBINED WITH 032
035 Cardiothoracic Surgery NEW-Combination of 009 & 032

7. BENEFICIARY Changes
Why Do I NEED to Use the New Beneficiary File
Number of Counties % Changed
Beneficiaries Changed in Counties 3038 94.1%
Beneficiaries Increased in Counties 2264 70.1%
Beneficiaries Decreased in Counties 773 23.9%
Counties Remained the Same 190 5.9%

8. MINIMUM PROVIDER Changes
Beneficiary Count Changes -> Minimum Provider Changes
Number of Counties % Changed
Counties That Changed Number of Required Beds 916 28.4%
Counties That Changed Minimum Number of Providers 321 9.9%

9. 2014 PROVIDER T/D Requirements
2014 Provider Time and Distance Requirements
Geographic Type
Large Metro Metro Micro Rural CEAC
CMS Code Specialty
Time Distance Time Distance Time Distance Time Distance Time Distance
(minutes) (miles) (minutes) (miles) (minutes) (miles) (minutes) (miles) (minutes) (miles)
001 General Practice
002 Family Practice
003 Internal Medicine
004 Geriatrics
005 Primary Care - Physician
006 Primary Care - Nurse
S03 Primary Care 10 5 15 10 30 20 40 30 70 60
007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110
008 Cardiology 20 10 30 20 50 35 75 60 95 85
010 Chiropractor 30 15 45 30 80 60 90 75 125 110
011 Dermatology 20 10 45 30 60 45 75 60 110 100
012 Endocrinology 30 15 60 40 100 75 110 90 145 130
013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110
014 Gastroenterology 20 10 45 30 60 45 75 60 110 100
015 General Surgery 20 10 30 20 50 35 75 60 95 85
016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110
017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130
018 Nephrology 30 15 45 30 80 60 90 75 125 110
019 Neurology 20 10 45 30 60 45 75 60 110 100
020 Neurosurgery 30 15 60 40 100 75 110 90 145 130
021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100
022 Oncology - Radiation/Radiation Oncology
30 15 60 40 100 75 110 90 145 130
023 Ophthalmology 20 10 30 20 50 35 75 60 95 85
025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85
026 Physiatry, Rehabilitative Medicine
30 15 45 30 80 60 90 75 125 110
027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130
028 Podiatry 20 10 45 30 60 45 75 60 110 100
029 Psychiatry 20 10 45 30 60 45 75 60 110 100
030 Pulmonology 20 10 45 30 60 45 75 60 110 100
031 Rheumatology 30 15 60 40 100 75 110 90 145 130
033 Urology 20 10 45 30 60 45 75 60 110 100
034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130
035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130
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10. 2014 FACILITY T/D Requirements
2014 Provider Time and Distance Requirements
Geographic Type
Large Metro Metro Micro Rural CEAC
CMS Code Specialty Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum
Number/ Time Distance Number/ Time Distance Number/ Time Distance Number/ Time Distance Number/ Time Distance
1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles)
040 Acute Inpatient Hospitals 12.2 20 10 12.2 45 30 12.2 80 60 12.2 75 60 12.2 110 100
041 Cardiac Surgery Program NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
042 Cardiac Catheterization Services NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
043 Critical Care Services – Intensive Care Units (ICU) NA 20 10 NA 45 30 NA 160 120 NA 145 120 NA 155 140
044 Outpatient Dialysis NA 20 10 NA 45 30 NA 65 50 NA 55 50 NA 100 90
045 Surgical Services (Outpatient or ASC) NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
046 Skilled Nursing Facilities NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 95 85
047 Diagnostic Radiology NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
048 Mammography NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
049 Physical Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
050 Occupational Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
051 Speech Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
052 Inpatient Psychiatric Facility Services NA 30 15 NA 70 45 NA 100 75 NA 90 75 NA 155 140
054 Orthotics and Prosthetics NA 30 15 NA 45 30 NA 160 120 NA 145 120 NA 155 140
055 Home Health NA NA NA NA NA
056 Durable Medical Equipment NA NA NA NA NA
057 Outpatient Infusion/Chemotherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
061 Heart Transplant Program NA NA NA NA NA
062 Heart/Lung Transplant NA NA NA NA NA
064 Kidney Transplant Program NA NA NA NA NA
065 Liver Transplant Program NA NA NA NA NA
066 Lung Transplant Program NA NA NA NA NA
067 Pancreas Transplant Program NA NA NA NA NA
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11. MEDICARE & DUAL
Demonstrations
Quest Analytics

12. NOIA’s Submitted
 Offering a new product type (such as a MA-PD, or Medicare-
Medicaid Plan)
 Transitioning an existing non-or partial network PFFS to a full
network PFFS Expanding the service area of an existing contract
(SAE)
 Expanding only an employer-only service area
 Adding prescription drug benefits to an existing contract for the
first time
 Adding Employer Group Waiver Plan (EGWP) market to an existing
individual
 Adding individual market to an existing EGWP-only service area for
the first time
 Adding or expanding the service area of a Special Needs Plan
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13. Dual Demonstration States
 Light Blue: Capitated Managed Care Model
http://dualsdemoadvocacy.org/  Dark Blue: Managed Fee-for-Service Model
 Green: Pursuing both models
 Maroon: Not seeking demonstration
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14. States on the HOT SEAT
2014 Notice of Intent to
Apply as a Medicare-
Medicaid Plan through the
Financial Alignment
Demonstration were due
on November 14th for the
highlighted states on right.
CY 2014 applications will
be posted on CMS website
by January 10, 2013.
Applications will be due
on February 21, 3013,
to include a network
compliant with CMS
Medicare standards.
http://dualsdemoadvocacy.org/

15. CMS APPLICATION
Quest Analytics

16. A NEW MODEL EVOLVES
CMS Revamps the process to:
1. Address geographic disparities across any state
2. Prevent adverse selection
3. Provide transparency of requirements
4. Apply consistency across plans
5. Leverage across programs

17. COUNTY CLASS Methodology
COUNTY TYPES
CMS created
5 county types using
population/density
parameters defined
on the right
 Large Metro
 Metro
 Micro
 Rural
 Counties with
Extreme Access
Criteria (CEAC)

18. ADEQUACY Methodology
Two primary adequacy criteria:
Minimum number of providers
 Must contract with sufficient numbers of each provider specialty
type
 Must contract with sufficient number of each HSD facility type
Maximum Travel Time & Distance to Providers/Facilities
 90% of beneficiaries have access to at least one provider/facility
 Contracted providers are not limited to the boundaries of the
county or counties as long as the provider is within the time &
distance requirement
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19. 2014 PROVIDER T/D Requirements
2014 Provider Time and Distance Requirements
Geographic Type
Large Metro Metro Micro Rural CEAC
CMS Code Specialty
Time Distance Time Distance Time Distance Time Distance Time Distance
(minutes) (miles) (minutes) (miles) (minutes) (miles) (minutes) (miles) (minutes) (miles)
001 General Practice
002 Family Practice
003 Internal Medicine
004 Geriatrics
005 Primary Care - Physician
006 Primary Care - Nurse
S03 Primary Care 10 5 15 10 30 20 40 30 70 60
007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110
008 Cardiology 20 10 30 20 50 35 75 60 95 85
010 Chiropractor 30 15 45 30 80 60 90 75 125 110
011 Dermatology 20 10 45 30 60 45 75 60 110 100
012 Endocrinology 30 15 60 40 100 75 110 90 145 130
013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110
014 Gastroenterology 20 10 45 30 60 45 75 60 110 100
015 General Surgery 20 10 30 20 50 35 75 60 95 85
016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110
017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130
018 Nephrology 30 15 45 30 80 60 90 75 125 110
019 Neurology 20 10 45 30 60 45 75 60 110 100
020 Neurosurgery 30 15 60 40 100 75 110 90 145 130
021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100
022 Oncology - Radiation/Radiation Oncology
30 15 60 40 100 75 110 90 145 130
023 Ophthalmology 20 10 30 20 50 35 75 60 95 85
025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85
026 Physiatry, Rehabilitative Medicine
30 15 45 30 80 60 90 75 125 110
027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130
028 Podiatry 20 10 45 30 60 45 75 60 110 100
029 Psychiatry 20 10 45 30 60 45 75 60 110 100
030 Pulmonology 20 10 45 30 60 45 75 60 110 100
031 Rheumatology 30 15 60 40 100 75 110 90 145 130
033 Urology 20 10 45 30 60 45 75 60 110 100
034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130
035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130
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20. 2014 FACILITY T/D Requirements
2014 Provider Time and Distance Requirements
Geographic Type
Large Metro Metro Micro Rural CEAC
CMS Code Specialty Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum Maximum
Number/ Time Distance Number/ Time Distance Number/ Time Distance Number/ Time Distance Number/ Time Distance
1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles) 1,000 (minutes) (miles)
040 Acute Inpatient Hospitals 12.2 20 10 12.2 45 30 12.2 80 60 12.2 75 60 12.2 110 100
041 Cardiac Surgery Program NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
042 Cardiac Catheterization Services NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140
043 Critical Care Services – Intensive Care Units (ICU) NA 20 10 NA 45 30 NA 160 120 NA 145 120 NA 155 140
044 Outpatient Dialysis NA 20 10 NA 45 30 NA 65 50 NA 55 50 NA 100 90
045 Surgical Services (Outpatient or ASC) NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
046 Skilled Nursing Facilities NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 95 85
047 Diagnostic Radiology NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
048 Mammography NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
049 Physical Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
050 Occupational Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
051 Speech Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
052 Inpatient Psychiatric Facility Services NA 30 15 NA 70 45 NA 100 75 NA 90 75 NA 155 140
054 Orthotics and Prosthetics NA 30 15 NA 45 30 NA 160 120 NA 145 120 NA 155 140
055 Home Health NA NA NA NA NA
056 Durable Medical Equipment NA NA NA NA NA
057 Outpatient Infusion/Chemotherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100
061 Heart Transplant Program NA NA NA NA NA
062 Heart/Lung Transplant NA NA NA NA NA
064 Kidney Transplant Program NA NA NA NA NA
065 Liver Transplant Program NA NA NA NA NA
066 Lung Transplant Program NA NA NA NA NA
067 Pancreas Transplant Program NA NA NA NA NA
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21. Where can I find more DETAILS?
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22. How are you going to do this?
Quest Analytics

23. Will you be spending a lot of time
GOOGLE MAPPING?
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©2012

24. Is your TIME & DISTANCE correct?
All of these requirements are
embedded into the
Quest Suite.

25. Will you end up with a MESS?
All of these requirements are
embedded into the
Quest Suite.

26. Will you be searching from the right
BENEFICIARY POINTS?
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©2012

27. One Doc … MULTIPLE COUNTIES
Milwaukee
County
LM=15 M
Waukesha
County
ME=40 MI
Richland
County
RU=90 MI All of these requirements are
embedded into the
Quest Suite.
Green
County
MI=75 MI
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28. One Hospital … MULTIPLE SERVICES
045
043
044
047
050 061
041 051
040
042 049
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29. Do you want to avoid CMS Errors?

30. There’s a
better way
to power
YOUR
HSD TABLES
Quest Analytic Suite™

31. PROVEN Partnership
+
 2007 CMS Partnership BEGINS with Part D
 2009 CMS Partnership EXPANDS to Part C
 2012 CMS REQUIRES Medicare Standards for Dual
Demonstration Projects
 2013 Network Adequacy at the FOREFRONT of
Qualifying and Monitoring Plans for the Exchanges
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32. ADVANTAGES with Quest Analytics
 Begin testing TODAY (Released 12/12/12)
 Network Adequacy 24/7/365
 Beneficiary File EMBEDDED
 T/D & Minimum Providers EMBEDDED
 All Counties, SSAs, & Classes EMBEDDED
 Gap Map ANALYSIS
 NPI DATABASE
 AUTOMATE MA Tables (HSDs)
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33. Latest ENHANCEMENTS
 SIMULTANEOUS time & distance reporting
 Review only SELECTED specialties
 MINIMIZE out-of-county providers
 UPDATED geocoding
 NPI DATABASE
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34. CHALLENGES with the MA Tables
MA Provider Table
This table captures information on the specific physicians/providers in the
applicant’s contracted network.
If a provider serves beneficiaries residing in multiple counties in the service
area, list the provider multiple times with the appropriate state/county
code to account for each county served.
Providers that have opted out of Medicare cannot be included in the
applicant’s contracted network or on this table.
MA Facility Table
If a facility offers more than one of the defined services and/or provides
services in multiple counties, the facility should be listed multiple times
with the appropriate “SSA State/County Code” and “Specialty Code” for
each service.
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35. MEDICARE ADVANTAGE
MODULE
How can we help? Quest Analytics

36. VALUE PROPOSITION
Quest Analytics

37. Providing Network Adequacy SOLUTIONS
 Answers to the test
Complete First Run of Network Adequacy Pass/Fail Results with MA
Provider and Facility Tables
Deliver Quest Analytics Software Suite, with completed project file,
including one day onsite training
 A long-term solution
in place to review network changes and “what if” scenarios
 Software updates
including year-over-year criteria changes
 (Optional)
Narrow Network or Targeted Gap Consulting
Start analyzing your 2014 Application Goals, using the same solution as CMS!

38. QUEST ANALYTICS SUITE™
 ACCESS ANALYSIS
Access Analysis I Access Comparison
 ADEQUACY ANALYSIS
Medicare Advantage I Medicaid I Dual Eligibles I Exchanges
 DISRUPTION ANALYSIS
Transparency & Confidence I Provider Change Analysis
 GEOCODER & DATA STANDARDIZATION
Address-Level Accuracy I Data Standardization
 NARROW NETWORK ANALYSIS
Provider Ranking I Tiered Networks
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39. QUALITY
UNDERSTANDING
EVOLVING
SUPPORT
TEAM
Network Adequacy Experts Providing SIMPLE I CONSISTENT I PROVEN Solutions

40. Let’s Continue the CONVERSATION!
Account Managers
Darren Huff, Eastern Region
Darren.Huff@QuestAnalytics.com
Michelle LeCloux, Western Region
Michelle.LeCloux@QuestAnalytics.com
920.739.4552
Call for an Onsite Product Demonstration
and we’ll fly right over >>>