Minimum number of providers

Ensures network has sufficient providers to secure adequate access for beneficiaries. Based on expected Medicare beneficiaries’ healthcare utilization and differentiated between urban and rural markets. HSD table includes 27 provider specialties and 14 facility types. 

Time and Distance

Maximum Time/ Distance that a beneficiary would need to travel to access at least one provider of each specialty (or facility).

Takes into account the various county types (Large Metro, Metro, Micro, Rural and CEAC).

Beneficiaries Required to Cover

CMS determines the number of beneficiaries that would need to be covered in each county utilizing the 95th percentile of MAOs’ market share. This is the foundation to determine the minimum number of providers/ facilities.

Beneficiary Coverage Ratio

CMS requires that organizations contract with a sufficient number of providers and facilities to ensure that at least 90% of enrollees in a county (85% in some county types) can access care within a specific time and distance.  The goal is to ensure that the vast majority of beneficiaries in a county have adequate access