Building a Medicare Advantage Network

Background

The Health Plan is a not-for-profit health plan in the Northeast that services more than 280,000 members, offering Medicaid, Medicare and Children’s Health Insurance Program (CHIP) plans.

The plan has consistently ranked high on the National Committee for Quality Assurance’s (NCQA) quality metrics but had a relatively small footprint in its target markets, despite being a well-respected Medicaid plan. The health plan wanted to expand their Medicare Advantage plan in their state beyond their existing market and engaged COPE Health Solutions to mobilize quickly and complete the market research, analysis and network recruitment/build required to meet the rapidly approaching Centers for Medicare & Medicaid Services (CMS) Medicare Advantage submission deadline in order for the plan to have a larger network in the following calendar year.

Our Approach

COPE Health Solutions provided the network research, analytics, targeted recruitment and contracting support required to expand the health plan’s Medicare Advantage footprint into agreed upon counties in a large target region. The COPE Health Solutions team was responsible for identifying the targets, making the connections, negotiating and ultimately providing credentialing-ready files to the health plan for providers who agreed to join the network. In this effort, COPE Health Solutions contracting experts worked with single practitioners, multi-specialty groups, hospitals, large health systems and other key providers to ensure the health plan developed an adequate Medicare Advantage network across each of the 41 required specialties. The engagement team maintained a close relationship with the health plan through weekly status meetings to discuss challenges and review network adequacy reports.

Outcomes

For the 2020 submission, the health plan was able to submit an additional five counties for approval and will be able to market three new Medicare Advantage offerings in those counties. In a six-month time frame, COPE Health Solutions was able to expand the client health plan’s network by more than 3,000 providers, including key large health system contracts with outsize impact on network adequacy. The additional medical premium for the five new counties is estimated to be between $43M and $53M, based on a 5 percent to 6 percent capture of eligible enrollees and is consistent with the market share in previously existing counties.

The firm is currently engaged with the health plan for a Phase 2, in which the COPE Health Solutions team is charged with expanding the network to an additional 47 counties for the 2021 submission to CMS.