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Consideration for Health Equity Measures in Network Adequacy Standards

One way to advance health equity standards through the QHP certification process is to incorporate health equity-based network adequacy standards into the network adequacy review process. 

The Affordable Care Act (ACA) directed the Centers for Medicare & Medicaid Services (CMS) to establish rules to require that Exchange health plans ensure a sufficient choice of providers.1 To implement this requirement, CMS adopted quantitative standards, which require Exchange health plans to ensure that its network providers are available to members within specified time and distance measures.2  Taken together, these laws laid the initial foundation for what we know as network adequacy requirements that apply to Exchange health plans today. Since the passage of the ACA, both Congress and CMS have continued to build on network adequacy by adding more requirements with the goal of enhancing access to quality, affordable care through the Exchanges.3

In recent years, efforts to improve Exchange health plan responsiveness to the health equity status of its members have become a major area of focus. Health equity is generally understood to be a state in which every person has the opportunity to achieve their full health potential, and in which no person is disadvantaged because of social circumstances.4 In alignment with a recent Executive Order (EO)5, which established a government-wide approach to advancing equity, CMS is seeking input on methods to analyze data to inform future Exchange health plan network adequacy standards that impact health equity.6

The Framework for Network Adequacy Reviews

In recent comments to CMS’ request for input on network adequacy standards that impact health equity, Quest Analytics recommended CMS create a framework to allow it to move thoughtfully through the development of health equity network standards over multiple plan years. This will allow CMS to build consensus around, and implement, health equity measures as a part of Exchange health plan network adequacy reviews over time.

This framework involves two main pillars:

    1. Developing a selection of provider and facility characteristic types that are critical to meeting the health equity needs of Exchange membership.
    2. Developing a methodology for measuring access to the types developed in the first pillar for each county in the country.

This is achieved through the establishment of quantitative standards, which would include the development of a county-based health equity designation for each county. Taken together, this framework would constitute moving toward health plan health equity measures as part of CMS’ network adequacy review for Exchange health plans.

A Model for Regulators at All Levels to Consider

We welcome health plan regulators at all levels to review this framework for addressing the health equity needs of their consumers. You can read our full comments here.

Endnotes

  1. See 42 USC § 18031(c)(1)(B)
  2. See 45 CFR § 156.230(a)
  3. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023, p. 261 (proposed December 28, 2021)
  4. See CDC 2020
  5. See EO 13985
  6. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023, p. 261 (proposed December 28, 2021)