CMS-10636 Justification Template

CY 2018 Partial County Justification Template
Instructions: Organizations requesting service areas that include one or more partial counties
must upload a completed Partial County Justification into HPMS.
Complete and upload a Partial County Justification for each partial county in your current and
proposed service area. This template is appropriate for organizations (1) offering a current
partial county, (2) entering into a new partial county, or (3) expanding a current partial county by
one or more zip codes when the resulting service area will continue to be a partial county. This
template applies for any organization that has a partial county as part of its service area.
Organizations must complete and upload a Partial County Justification for any active/existing
partial county or pending/expanding partial county.
Organizations expanding from a partial county to a full county do NOT need to submit a Partial
County Justification.
HPMS will automatically assess the contracted provider and facility networks against the
current CMS network adequacy criteria. If the ACC report shows that an organization fails
the criteria for a given county/specialty, then the organization must submit an Exception
Request using the same process available for full-county service areas.
NOTE: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
Using just a few sentences, briefly describe why you are proposing a partial county service area.
SECTION II: Partial County Requirements
The Medicare Advantage Network Adequacy Criteria Guidance provides guidance on partial
county requirements. The following questions pertain to those requirements.
Explain how and submit documentation to show that the partial county meets all three of the
following criteria:
1. Necessary – It is not possible to establish a network of providers to serve the entire
county.
Describe the evidence that you are providing to substantiate the above statement and (if
applicable) attach it to this form.
2. Non-discriminatory – You must be able to demonstrate the following:
•

The anticipated enrollee health care cost in the portion of the county you are
proposing to serve is comparable to the excluded portion of the county.
Describe the evidence that you are providing to substantiate the above statement
and (if applicable) attach it to this form.

•

The racial and economic composition of the population in the portion of the county
you are proposing to serve is comparable to the excluded portion of the county.

OMB Control Number: 0938-New (Expires: TBD)

Describe the evidence that you are providing to substantiate the above statement
and (if applicable) attach it to this form.
3. In the Best Interests of the Beneficiaries – The partial county must be in the best
interests of the beneficiaries who are in the pending service area.
Describe the evidence that you are providing to substantiate the above statement and (if
applicable) attach it to this form.
SECTION III: Geography
Describe the geographic areas for the county, both inside and outside the proposed service area,
including the major population centers, transportation arteries, significant topographic features
(e.g., mountains, water barriers, large national park), and any other geographic factors that
affected your service area designation.

OMB Control Number: 0938-New (Expires: TBD)