The Centers for Medicare & Medicaid Services wants to ensure its provider networks adequately serve their beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) makes partially capitated payments to private insurers, also known as Part D sponsors, for delivering prescription drug benefits to Medicare beneficiaries. In order to receive these payments, Part D sponsors need to meet access standards set by CMS. By setting these standards, CMS helps ensure the availability of prescription drugs to seniors.

These access standards set a percentage of Medicare beneficiaries that need to be within a given distance bandwidth of the pharmacies within a Part D network. The standards vary by urbanicity, and whether a Part D sponsor’s pharmacy network contains preferred cost share pharmacies.

NORC conducts a quarterly geo-analysis of Medicare Part D provider networks.

In order to ensure Part D sponsors meet the access standards set by CMS, NORC provides a number of analytical files to CMS based on a multi-step GIS-based assessment of each sponsor’s provider network. Each sponsor’s provider network is assigned coordinates using NORC’s state of the art geocoding software. Sponsor service areas are then linked to extant population density data to categorize them by urbanicity. Finally, the percent of beneficiaries within each sponsor’s service area that are within CMS’s access standards is calculated, along with several additional statistics, such as the average distance to a pharmacy. 

This analysis is conducted quarterly to monitor compliance and identify outliers throughout the year. Additionally, NORC undertakes a more detailed yearly analysis, in which we pinpoint areas of the U.S. that are underserved by any Part D sponsor and determine the most commonly spoken languages within each plan’s service area.