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Network Adequacy and Provider Directory Accuracy Policy Updates

What to Watch: Network Adequacy and Provider Directory Accuracy Trends - November 2023

What’s the latest news on network adequacy and provider directory accuracy? Here’s what took place in November.

Federal Policy Updates

Proposed Rule: 2025 Medicare Advantage Program

New Mental Health Facility-Specialty Type and Network Adequacy Exceptions

The Centers for Medicare & Medicaid Services (CMS) proposed changes to the Medicare Advantage program for the contract year 2025. The rule included two amendments related to network adequacy standards.

  1. Addition of Outpatient Behavioral Health as a Facility-Specialty Type: As part of the proposed rule, CMS recommended adding “Outpatient Behavioral Health” as a facility-specialty type to the network adequacy requirements for Medicare Advantage organizations.

  2. Expanded Network Adequacy Exception Bases for Facility-Based Institutional Special Needs Plans (I-SNPs): The proposed rule also recommended two additional bases for facility-based I-SNPs to request network adequacy exceptions. These exceptions would apply in cases where (1) there is an inability to contract with certain specialty types due to the unique care model of facility-based I-SNPs or (2) there is adequate access to basic benefits through additional telehealth services when using telehealth providers instead of in-person providers to fulfill network adequacy standards.

Medicare Advantage Proposed Changes

Learn about the proposed changes for the Medicare Advantage Program in Contract Year 2025. Our brief provides a comprehensive overview of potential updates to network adequacy and provider directory accuracy requirements. Download it now for all the essential details.

Download The Policy Brief Now!

Proposed Rule: 2025 Notice of Benefit and Payment Parameters

Amending State Exchange Network Adequacy Requirements

CMS released the Notice of Benefit and Payment Parameters (Payment Notice) for the 2025 proposed rule. Notably, the rule aims to amend network adequacy requirements for State-Based Exchanges (State Exchanges) and State-Based Federally-Facilitated Exchanges (SBE-FPs) certifying issuers as qualified health plans (QHPs). The proposed changes include:

  1. Quantitative Network Adequacy Standards: Create and enforce quantitative time and distance network adequacy standards for QHPs that are equivalent to those for QHPs on the Federally-Facilitated Exchanges (FFEs). This includes provider lists and county classifications.
  2. Quantitative Network Adequacy Reviews: Conduct quantitative network adequacy reviews before certifying any plan as a QHP, consistent with the reviews conducted by the FFEs. Issuers would no longer attest to the adequacy of their networks. They would be required to provide evidence that they meet network adequacy standards.
  3. Justification Process for Applicants Unable to Meet Standards: Applicants who fail to meet the network adequacy standards would have the opportunity to participate in a network adequacy justification process to potentially earn their QHP certification.
  4. Reporting on Telehealth Services: Issuers seeking QHP certification would be required to submit information about whether network providers offer telehealth services.
Four New Network Adequacy Requirements for QHP Certification

Proposed Rule for QHP Certification

CMS released its proposed Notice of Benefit and Payment Parameters (NBPP) rule for the 2025 plan year (PY 2025). Notably, it includes amendments to network adequacy requirements for State-Based Exchanges (State Exchanges) and State-Based Exchanges using the Federal Platform (SBE-FPs) to align with federal standards. Download our policy brief for more information.

Making Moves: The Requiring Enhanced & Accurate Lists of Health Providers Act

New Policy Aimed at Ghost Networks in Medicare Advantage Organizations Included in Senate Finance Package

The Requiring Enhanced & Accurate Lists of Health Providers Act, also known as the REAL Health Providers Act, is a proposed policy that aims to prevent ghost networks by imposing additional requirements on Medicare Advantage plans to maintain accurate provider directories. On November 8, 2023, the REAL Health Providers Act was passed by the Senate Finance Committee as part of the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act. The chairman’s markup is available here.

Congressional Budget Office Evaluation: An evaluation conducted by the Congressional Budget Office found that the implementation of the REAL Health Providers Act would require a federal investment of $55 million between 2024 and 2028. We’ll continue to keep you updated on any developments as it moves through the legislative process.

CMS Bulletin: Medicaid and Chip Managed Care Monitoring And Oversight Tools

States Reminded of Network Adequacy and Access Assurances Report Annual Submission Requirement

CMS issued its third Center for Medicaid and CHIP Services (CMCS) Informational Bulletin (CIB), providing additional information and tools for States and CMS to improve the monitoring and oversight of managed care in Medicaid and the Children’s Health Insurance Program (CHIP). Included is guidance for states about how to implement federal Managed Care Organization network adequacy standards.

Additionally, the bulletin reminds the states that they are required to submit a Network Adequacy and Access Assurances Report (NAAAR) annually. This report must include documentation of an analysis that supports network adequacy for each Managed Care Organization provider network.

Congressional Agency Meeting: Medicare Payment Advisory Commission

Evaluating Medicare Advantage Network Adequacy and Accuracy Compliance

The Medicare Payment Advisory Commission (MedPAC), which is a legislative branch agency that provides Congress with analysis and policy advice about Medicare, held a meeting on November 3, 2023, to discuss Medicare Advantage network adequacy compliance and enforcement issues.

During the session, MedPAC announced its plan to conduct an analysis and literature review on how CMS regulates the use of network adequacy tools and the data reported by Medicare Advantage plans in these areas. One Commissioner requested that MedPAC staff propose new time and distance measures that specifically consider the needs of low-income Medicare Advantage beneficiaries, with access to providers near public transit. Another Commissioner suggested that CMS verify the accuracy of provider directories by analyzing claims data to determine if the listed providers are actively treating patients for the specified plan.

Press Release: American Medical Association Urges New Network Adequacy Standards

Advocating for Improved Regulatory Oversight

The American Medical Association (AMA) House of Delegates voted to adopt AMA policy supporting the establishment and enforcement of standards to strengthen network adequacy. Due to state variability in network adequacy oversight, the AMA intends to establish a minimum network adequacy standard for health plans. The AMA president emphasized the importance of prioritizing network adequacy to ensure patients can access care. Additionally, the president expressed optimism that the new policy would improve monitoring and enforcement, effectively holding health plans accountable for networks that are too narrow.

Press Release: Spotlighting Network Adequacy Policies

CMS Efforts to Address Access Challenges in Rural Communities

The Department of Health and Human Services (HHS) published a press release highlighting the policies implemented by CMS to address access challenges and improve network adequacy in rural areas. Here are a few of the rules and policies established by CMS to achieve this goal.

2024 Medicare Advantage Rule: Inclusion of Two Behavioral Health Specialties

The 2024 Medicare Advantage Rule added two behavioral health provider specialties: Clinical Psychology and Clinical Social Work. In addition, CMS introduced appointment wait time standards for behavioral health and primary care providers. 

2024 Notice of Benefit and Payment Parameters Rule: Expansion of Essential Community Providers

The 2024 Notice of Benefit and Payment Parameters Rule expanded the categories of Essential Community Providers (ECPs) to include Substance Use Disorder Treatment Centers and Mental Health Facilities. CMS also classified Rural Emergency Hospitals (REHs) as a provider type under the Other ECP Providers category.

2023 Two Medicaid Proposed Rules: Increased Transparency and Timely Access to Services

CMS issued two proposed rules in April 2023, to address access challenges that disproportionately affect rural communities. Finalization of these rules would increase transparency in provider payments, which would potentially incentivize increased participation in Medicaid by various providers, including those located in rural areas. To ensure timely access to services, the proposed rules would impose appointment wait time standards for beneficiaries receiving specific services through managed care, including routine primary care, OB-GYN services, and outpatient mental health and substance use disorder services.

State Policy Updates

Oklahoma Insurance Department

Legislative Changes to Provider Directory Accuracy Requirements

The Oklahoma Insurance Department released a bulletin unveiling legislative changes designed to improve health benefit plan directory accuracy.

Removal of Inactive Providers From the Directories

Under the revised requirements, health benefit plans are now required to remove providers from their directories when the provider has not submitted a claim within the last twelve months.

Reporting Requirements: Annual Provider Directory Audit
To ensure compliance and transparency, health benefit plan insurers must submit an Annual Provider Directory Audit Report to the Oklahoma Insurance Department. This report needs to be submitted by March 1, 2025, and subsequently on every March 1st thereafter. The report must include, at a minimum, the following information:

  • The number of reports received by the health benefit plan regarding inaccurate directory information.
  • The timeframe in which the plan responded to these reports.
  • The correction(s) actions taken by the health benefit plan.
  • All relevant documentation and reports of any audits conducted by the plan upon receiving notification of inaccurate information in the directory.

Oregon Health Authority

Proposed Health Equity Provider Characteristics in Directories

The Oregon Health Authority has proposed a rule to amend existing provider directory requirements for Managed Care Entities. The proposed changes include Managed Care Entities reporting on provider information related to Race, Ethnicity, Language and Disability (REAL-D)/Sexual Orientation or Gender Identity (SOGI). This amendment supplements the current requirement for Managed Care Entities to report on a provider’s cultural and linguistic capabilities, including languages.

Tip: Learn about the additional network adequacy amendments Oregon Health Authority previously proposed.

Massachusetts Department of Insurance

Finalized Rule on Network Adequacy and Provider Verification Requirements

The Massachusetts Department of Insurance has finalized a rule that amends requirements for network adequacy, provider data verification, and provider claims analysis. These changes also include new telehealth-related network adequacy requirements for behavioral health, chronic disease management, and primary care. As part of the rule, health plans are required to educate providers about regularly updating and verifying their information every 90 days.

Massachusetts Legislation

Study on Medicare ACO Network Adequacy

The Massachusetts Health Policy Commission has been authorized to conduct a study on the network adequacy of Medicare Accountable Care Organizations (ACOs) participating in the state’s Medicare Shared Savings Program. The study results will be published before December 31, 2024, as mandated by updated legislation.

Missouri Department of Commerce and Insurance

Press Release Highlights Provider Directory Accuracy During Open Enrollment

The Missouri Department of Commerce and Insurance emphasized the need for accurate provider directory data during open enrollment. They urge consumers to verify that their current providers are included in the network of any health plan they are considering. The department also suggested that consumers directly contact healthcare providers to ensure they will be in-network for the upcoming year to prevent future problems. They explained that a health carrier’s provider directory only provides a snapshot of the plan’s network at a specific moment.

Future Developments: Network Adequacy and Provider Directory Accuracy

Looking ahead, we anticipate further updates to federal and state network adequacy and provider data accuracy requirements. Rest assured, we’ll keep you in the loop about the latest developments in these areas. If you have questions about the recent updates or other network adequacy and provider directory accuracy policies, don’t hesitate to contact us.

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