Medicare Advantage Network Adequacy Rules

CMS Updates to Medicare Advantage Network Adequacy Rules: What It Means for Anesthesiologists

Background and ASA Advocacy

Medicare Advantage (MA) plans are required to maintain provider networks that meet CMS’s network adequacy standards, including time-and-distance requirements for multiple specialties. Since adoption of 42 C.F.R. §422.116 in 2020, ASA has consistently urged CMS to ensure that anesthesiologists and pain medicine physicians are explicitly included among the specialties required for network adequacy, however CMS has not done so. This update provides the background and current status of network requirements for MA plans.

In 2022, ASA submitted formal comments on CMS’s proposed changes for CY 2023, emphasizing several key points:

Support for Adequacy Demonstrations: ASA supported CMS’s proposal requiring MA plans to demonstrate adequacy as part of their application process.
Explicit Specialty Inclusion: ASA urged CMS to add anesthesiologists and pain medicine specialists to the list of specialties CMS explicitly tracks for adequacy.
Transparency in Criteria: ASA recommended that inclusion criteria used by MA plans to determine which physicians and groups are required to join networks be submitted by the MA plans to CMS and made publicly available.
Ongoing Monitoring: ASA emphasized the need for annual data submission and monitoring, rather than the current triennial reviews.
Response to Market Trends: ASA flagged a troubling trend of MA plans specifically excluding anesthesiologists—potentially tied to implementation of the No Surprises Act—and pressed CMS to adopt stronger guardrails to ensure beneficiaries retain access to anesthesia services.

Despite these requests, anesthesiology was not added to CMS’s monitored specialty list.

New CMS Proposals (2025–2027)

CMS recently issued proposals and guidance aimed at improving MA provider directories and transparency:

Public Directory Integration: MA provider directory data would be submitted to CMS/HHS for publication online, improving beneficiary access to accurate information.
Timely Updates: MA organizations must update directory information within 30 days of becoming aware of changes.
Annual Attestation: Plans must attest annually that directory data are accurate.
Partial Attestation Dropped: CMS chose not to finalize a provision requiring plans to attest that directory data align with data used to demonstrate adequacy.

Implications for Anesthesiologists

CMS has made some changes in the requirements related to provider directories and improvements in correcting directory errors. While these might be of value for other specialties, the implications for anesthesiologists are limited, since CMS still does not explicitly include anesthesiologists and pain medicine specialists in its network adequacy reviews.

Ongoing Concerns

Exclusion from Tracked Specialties continues to put anesthesiology practices at risk, since CMS still does not explicitly include anesthesiologists and pain medicine specialists in its network adequacy reviews.
Lack of inclusion in directories diminishes anesthesiologists’ ability to fairly negotiate with MA plans when payment is denied.
The current CMS position can be misleading to patients. Beneficiaries seeking surgical care may incorrectly assume that if a facility is in-network with an MA plan then the anesthesiology practice is too, however it may not be. When anesthesiologists and pain medicine physicians are not specifically included in MA network adequacy reviews, patient access to safe anesthesia and pain care is at risk, leading to financial implications for facilities and anesthesiologists.

Read about ASA Advocacy efforts:
ASA Urges CMS to Expand Medicare Advantage Network Adequacy Standards to Include Anesthesiology