Policy Trends Across Health Insurance Markets

What to Watch: Network Adequacy and Provider Directory Accuracy Trends

The data is in—and it’s clear: provider network oversight, provider data accuracy and provider data transparency are the hot trends across all health insurance markets.

But what does this mean for you? Here’s the inside scoop on what’s going on in the industry right now, what changes are coming down the pike and how to maximize your chances of success.


Regulators and policymakers continue to make changes that strengthen federal and state oversight processes for Medicare Advantage, Marketplace, and Medicaid Health Plans. Let’s look at what’s happening in each market.

Medicare Advantage: Network Adequacy Requirements for Applications

In a previous blog post, we discussed how the Centers for Medicare & Medicaid Services (CMS) has reinstated network adequacy reviews as a condition of an initial or service area expansion application. This means that Medicare Advantage organizations (MAOs) now must demonstrate that their proposed provider network meets the requirements for: number of primary care providers (PCPs) and specialists, within the designated time and distance standards. Most notably, this means that Medicare Advantage organizations will need to build and evaluate provider networks long before submission.

What’s Next? CMS Requests Input on Improving Medicare Advantage Program

CMS is seeking public feedback on ways to improve Medicare Advantage, and we encourage you to take a minute to share your thoughts.

CMS released a Request for Information seeking public comment on the Medicare Advantage program. CMS is asking for input on ways to achieve the agency’s vision so that all parts of Medicare are working towards a future where people with Medicare receive more equitable, high quality, and person-centered care that is affordable and sustainable. 


Scott Westover and Michael Adelberg discuss how the new rules and provider network oversight processes in other insurance markets inform how CMS thinks about Medicare Advantage oversight.

Catch the full conversation to get more insider insights about the current landscape: Understanding the Network Adequacy Changes in the MA Final Rule.

Federally-facilitated Marketplace: New Network Adequacy Oversight

You may have heard, the federal government has resumed oversight of qualified health plans (QHPs) offered on healthcare.gov (the ACA marketplaces). This means that they’re back to being the regulatory body for these plans, and they have some new network adequacy requirements in place for QHP certification. With more to come next year. If you don’t know what these changes are, don’t worry—we’ve got you covered. Download our legislative brief now to get all the details.

What’s Next? New Network Adequacy Standards

As part of the new network adequacy standards, CMS is taking a closer look at appointment wait times and telehealth services. Look for CMS to provide additional guidance on these standards as they become more familiar with them, and ultimately incorporate them into their regular review process for insurers offering coverage through the marketplace.


Medicare-Medicaid Plan: Network Submission Coming Up

Every year, CMS reviews the adequacy of each Medicare-Medicaid Plan’s contracted provider network. This is a crucial part of ensuring that patients have access to appropriate care when they need it most.

Reminder: The 2022 initial submission will be due in the CMS Health Plan Management System (HPMS) by 8pm Eastern time on September 20, 2022. You can find more information and guidance for MMP standards for annual network adequacy on CMS’s website.

What’s Next? Potentially New Network Adequacy Standards

Earlier in the year, CMS issued a Request of Information: Access to Care and Coverage for People Enrolled in Medicaid and CHIP. According to CMS, the feedback they receive will help inform future polices, monitoring, and regulatory actions, helping ensure beneficiaries have equitable access to high-quality and appropriate care across all Medicaid and CHIP payment and delivery systems, including fee-for-service, managed care, and alternative payment models. Additionally, the comments will inform the agency’s future work to ensure timely access to critical services, such as behavioral health care and home and community-based services.1

Medicaid and CHIP Managed Care: New Network Adequacy and Access Assurances Report for States

States are now required to report Network Adequacy to CMS annually as well as for any new plan and if there is a significant network change. The new reporting requirement is part of a larger effort by CMS to strengthen the monitoring and oversight of Medicaid and CHIP Managed Care programs. The aim is to make sure that states are providing beneficiaries with access to adequate health care networks.2

Our team is continually collaborating with federal policymakers, State Insurance Commissioners and State Medicaid Directors, helping them develop strong oversight of health plans and to ensure they meet all federal and state regulatory requirements. We welcome the opportunity to meet with you and discuss how we can further support your efforts to improve access to care. Learn More 


Provider data accuracy and data transparency rules are top-of-mind for health insurers and providers alike. The Consolidated Appropriations Act (CAA), No Surprises Act (NSA), and the Transparency in Coverage Rule (TiC) introduced a flurry of activity around health plan transparency and provider data accuracy which have skyrocketed in the last year, and things have undoubtedly changed. Here are key provisions you need to know:

New Rules for Accurate Provider Directory Data

As a part of the CAA, the No Surprises Act, has brought a new level of scrutiny to provider data. In the most simplistic form, the rule requires health plans, providers, and health care facilities to keep the information in the provider directory up to date and promptly notify participants about whether a particular provider is in-network.

This new standard of accuracy isn’t easy to meet—especially when it comes to collaborating with multiple teams and partners to quickly make changes in your database. We encourage you to reach out to our team for a complimentary strategy session to discuss how we can help you meet this challenge.

What’s Next?

While the No Surprises Act went into effect January 1, 2022, the agencies intend to issue additional guidance on the required provider directory verification process in the future.

You can count on us to bring you the latest & greatest on any changes in policy or procedure, so stay tuned!

Straightforward Guidance to Meet the Provider Directory Rules

We’re continuing to dish out all the need-to-know details on the No Surprises Act Provider Directory Rules. Head over to our Provider Data Accuracy Resource Hub now to access our latest updates, on-demand webinars, tips & tricks videos, and more. 

New Rules for Transparency of Provider Data

The Transparency in Coverage (TiC) Rule and the CAA require plans and issuers to make machine-readable files publicly available that will disclose the following sets of costs for items and services.

  1. In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.
  2. Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.

Beginning July 1, 2022, CMS will enforce applicable price transparency requirements. For plans and issuers that are subject to CMS’s enforcement authority and do not comply, CMS may take several enforcement actions, including: requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually under 45 CFR part 102, for each violation and for each individual affected by the violation.3

What’s Next?

To minimize the potential burden of the new requirements, a three-year phase-in approach was adopted. Health plans that prepare today can differentiate their offering in the market and create a competitive advantage. Phase 2 and Phase 3, which include additional requirements for an internet-based price comparison tool (or disclosure on paper, upon request) go into effect in 2023 and 2024.4

NQTL Comparative Analysis Requirement for Mental Health Parity

Federal and state policymakers are taking a variety of measures to improve access to mental health services and substance use disorder treatments. In a previous post, we discussed the CAA amended the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to provide important new protections for participants. The CAA requires health plans to conduct and document an analysis that compares the nonquantitative treatment limitations (NQTLs) applicable to benefits for mental health and substance use disorders to the nonquantitative treatment limitations applicable to medical and surgical benefits.

What’s Next?

The Departments of Labor, Health and Human Services and the Treasury issued their 2022 Report to Congress on their MHPAEA enforcement efforts. Some key takeaways from the report emphasize the urgency for the need for greater oversight on health plan provider directories and network adequacy. We expect to see future work focus on guidance on how these issues should be addressed by regulators and stakeholders alike. 


The future of health insurance is here, and it’s going to be a wild ride.

In this blog post, we’ve explored the top trends across multiple health insurance markets that are set to reshape the way we think about health plans and how they operate. These trends are set to impact everything from your customer experience and the way you manage provider networks to your ability to capture accurate data and make smart decisions based on it.

The key to success is being able to adapt quickly and easily so that your company can capitalize on these trends. If you are ready for what is coming next, then it will be a smooth transition for your business. Here are just a few ways you can stay ahead of these changes and ensure that your company is ready for what is coming next:
  1. Understand the new requirements and update your provider data management processes to be compliant with the new rules.
  2. Make sure that your compliance team is well-trained, knowledgeable and up-to-date on the latest regulations.
  3. Audit the tools you currently use and determine if they still meet your needs or if you need to modernize your process with tools already available, like Quest Enterprise Services.
  4. Ensure that the provider data you use to make decisions is accurate, reliable, and transparent.
  5. Use data-driven intelligence with predictive analytics to easily identify the right providers for your network.

The most important thing for companies looking to stay competitive in this new era is finding ways to increase their relevance through improved customer experience, better provider network management and more accurate data—and that’s where our team comes in.

We have years of experience helping companies like yours find ways to stay compliant and competitive. Schedule a complimentary strategy session today to learn more about how we can help. 


Biden-Harris Administration Announces Request for Information on Access to Care and Coverage for People Enrolled in Medicaid and CHIP; Press Release

HHS Provides States with Additional Resources to Improve Oversight and Ensure Access to Quality Care in Medicaid and CHIP Managed Care Programs; Press Release

Center for Medicaid and CHIP Services (CMSC) Informational Bulletin (CIB), Medicaid and CHIP Managed Care Monitoring and Oversight Tools

Centers for Medicare & Medicaid Services (CMS) Website: Health Plan Price Transparency

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