Network Adequacy and Provider Directory Accuracy Policy Updates

Health Policy News Discover the latest federal and state network adequacy and provider directory accuracy policy developments. Read the blog now!

Now that 2024 is fully underway, we’d like to bring you up to speed on the network adequacy and provider directory policy updates that emerged between December 2023 and February 2024. 

Federal Policy Updates

CMS Issues Request for Information on Medicare Advantage Data

The Centers for Medicare & Medicaid Services (CMS) opened the year with a comprehensive Request for Information, requesting comments on all aspects of data currently collected and not collected related to the Medicare Advantage program. Of particular interest are data-related recommendations related to beneficiary access to care including provider directories, networks, and health equity around data impacting beneficiary care access, provider directories, and health equity. Comments are due May 29, 2024. 



State Based Exchanges Comment on CCIIO Network Adequacy Proposal

A comment letter on the proposed 2025 Notice of Benefit and Payment Parameters (NBPP) signed by representatives from every State-Based Exchange (SBE) was sent to the Center for Consumer Information and Insurance Oversight (CCIIO). The comment letter requested clarification from CCIIO regarding their proposal that would require SBEs to adopt the same or more stringent network adequacy requirements to align with federal standards. Download our policy brief on the proposed rule for all the essential details.

State Policy Updates: Final Rules

Nevada Division of Insurance: New Dental Network Adequacy Requirements

The Nevada Department of Insurance (DOI) finalized new network adequacy requirements that require health plans to demonstrate access to dental provider types within new time and distance metrics. These changes aim to align the time and distance standards of SADPs more closely with those of the Federally-facilitated Exchange network adequacy requirements for Qualified Health Plans (QHPs). Ultimately, this alignment seeks to ensure members have access to a diverse range of dental providers, including orthodontists, periodontists, and oral surgeons. 

Oregon Health Authority: Overhauls Medicaid Network Adequacy Requirements

The Oregon Health Authority (OHA) has implemented a comprehensive overhaul of Medicaid network adequacy standards, effective January 1, 2024. These new standards will leverage “radius rings” and county data to ensure Managed Care Organizations provide sufficient access to designated providers.

State Policy Updates: Proposed Rules

Colorado Department of Insurance: New Network Adequacy Action Report

The Colorado Department of Insurance (DOI) has introduced a proposed rule, setting a new standard for “Colorado Option” health plans to submit a Network Adequacy Action Plan Report to the DOI if the health plan is not able to meet network adequacy requirements. The report would require health plans to detail how it reached out to providers and include a detailed plan on how it intends to come into compliance with standards in the future. 

Colorado Legislation: Network Adequacy Requirements for Mental Health

Colorado House Bill 24-1045 proposes to revise Colorado statutes related to network adequacy in which the commissioner of the Department of Insurance would review network adequacy requirements to determine if they are sufficient to require carriers to provide adequate access to mental health and substance use disorder treatment providers. The legislation would require the DOI to submit a report of its findings to the state legislation by September 30, 2025. 

Illinois Department of Insurance: New Provider Directory Audit Regulations with Provider Claims Element

The Illinois Department of Insurance (IL DOI) announced it intends to draft new provider directory audit regulations that will incorporate elements of a provider directory bulletin it issued last year (2023-10) that requires health plans to engage in a self-audit and remove providers that have not submitted a claim within the last year. 

Illinois Legislation: Align Network Adequacy Requirements with the Federal Exchange Standards

Illinois House Bill 5395 proposes to amend the Network Adequacy and Transparency Act by adding definitions and aligning the network adequacy requirements to those established for qualified health plans (QHPs) in Federally-facilitated Exchanges (FFEs) by federal law CCIIO or by the federal Centers for Medicare & Medicaid Services (CMS). This legislation was introduced after CMS announced in its proposed 2025 NBPP rule that it, if finalized, would require SBEs to enact network adequacy requirements that match the requirements set by CCIIO. To learn more, download our policy brief on the proposed rule for state-based exchanges to align with the network adequacy requirements in the Federally-facilitated exchanges.

If passed, the amendments would be effective immediately. 

Kentucky Legislation: New Medicaid Oversight and Advisory Board Focused on Network Adequacy

Kentucky House Bill 316 proposes a Medicaid Oversight Committee was introduced in the state legislative session. The Committee would be required to propose network adequacy policy recommendations to the state legislature in future years.

New Jersey Legislation: New Medicaid Managed Care Organization Oversight Program Focused on Network Adequacy and Claims Activity

New Jersey Senate Bill 1818 proposes to create a Medicaid Managed Care Organizations (MCO) Oversight Program. The legislation is based on a report from the Office of the State Auditor, which found that MCOs did not provide sufficient access to general acute care hospital service networks and dental providers. The report also highlighted inaccuracies in the provider directories maintained by the MCOs, and a failure to report providers’ claims inactivity to the state Medicaid agency. To address these concerns, the proposed Medicaid MCO Oversight Program will require MCOs to submit updated provider data and beneficiary data quarterly. The Medicaid MCO Oversight Program will specify the required format, which will be consistent for all MCO contractors. The data submitted must include updated contact and location information for every provider and beneficiary. 

Additionally, the Medicaid MCO Oversight Program will mandate MCO contractors to submit annual claims inactivity reports for providers who meet the criteria established by the program.

New Jersey Legislation: New Network Adequacy Standards

New Jersey Senate Bill 2406 proposes new time and distance requirements for health benefits plans and carriers to ensure network adequacy, specifically for mental health care. The bill mandates that the Commissioner of Banking and Insurance or the Commissioner of Human Services create the new requirements. Additionally, the legislation states that if a mental health provider is not available within the defined time and distance metrics, telehealth or telemedicine services must be considered as an alternative.

New Jersey Assembly Bill 1873 proposes legislation to establish new network adequacy requirements for carriers. 

Texas Department of Insurance: Align Network Adequacy Requirements with the Federal Exchange Standards

The Texas Department of Insurance proposed changes to the network adequacy standards, incorporating elements from Senate and House Bills. The proposed rule aims to align time and distance requirements with the requirements of the Federally-facilitated Exchanges. Additionally, the regulation would require health plans to submit an annual network adequacy report that includes a claims-based analysis.

Wisconsin Legislation: New Provider Directory Verification Requirements

Wisconsin Assembly Bill 789 proposes to revamp provider directory verification processes. Health plans would be required to actively confirm provider information quarterly and meet the communication needs of all members, including those with disabilities and limited English proficiency.

What to Watch

Minnesota Legislation: Budget Includes Funding For Network Adequacy

Minnesota House File 4140 includes funding for the Minnesota Department of Insurance to produce an assessment of the feasibility​ of a statewide provider directory and for reviews of provider networks to determine network adequacy. 

Minnesota Legislation: Commission Includes Network Adequacy Expertise

Minnesota House File 4060 introduces legislation to create the Minnesota Commission for Equitable Health Care​ Services. The commission will evaluate and report on how the healthcare system​ impacts Minnesotans’ experience with access, cost, and care.​ The commission must include members appointed by the commissioner of health.​ Of the commissioner of health’s appointments, one must have expertise in network adequacy for managed care plans.

Washington Legislation: Funding Included Focus on Network Adequacy

Washington House Bill 2104 would require the Health Care Authority (HCA) to deliver a report to the legislature that outlines, among other things, network adequacy challenges that persist for Medicaid Managed Care Organization patients seeking substance use disorder treatment.  

Future Network Adequacy and Provider Data Accuracy Rules

Coming Health Policy Changes to Strengthen Provider Network Oversight

Overall, it’s clear that the focus on network adequacy and provider data accuracy will only grow as we move forward. With many legislative sessions in progress, we expect updates on federal and state laws. Rest assured that we’ll keep you informed as we learn more. Stay tuned!

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