New Approach to Network Adequacy Oversight

New network adequacy standards are in the works. Health Issuers hold on to your hats because the new standards will have a major impact on the way you design, measure and contract your network.

Throughout 2021, the Department of Health & Human Services (HHS) has confirmed its plans to transfer oversight of network adequacy for Qualified Health Plans (QHPs) on the Federally-facilitated Exchanges (FFEs) back to CMS. Although the new standards are being developed, we’ve received a few clues about the changes we can expect.

In this blog, we’ll explore the clues — because we believe it’s never too early to start preparing for compliance changes.

New Time and Distance Standards Are Coming

HHS is considering adopting time and distance standards to assess network adequacy for Qualified Health Plans (QHPs). They anticipate these standards will:

  • Be informed by the current Medicare Advantage time and distance standards
  • Be measured at the county level
  • Implement methodologies that take into account local geographical and topographical features, for example
    • Bodies of water, unpassable mountainous areas, etc.
  • Take into account varied travel modes to estimate real-world access to care better, for example
    • Car, public transportation, etc
  • Take into consideration the availability of telemedicine services
  • Expand the use of JavaScript Object Notation (JSON) files, which exchange plans currently use to review provider directories.

HHS concluded its thoughts on network adequacy by suggesting it’s still early in the process, and that they are “carefully considering” other network adequacy standards, including appointment wait times.


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Network Adequacy Metrics to Support Equal Access

HHS agrees that network adequacy metrics need to support equitable access for all consumers. For future rulemaking, HHS is carefully considering standards that promote health equity. New provider directory requirements could include the following information:

  • Race/ Ethnicity
  • Languages spoken
  • Accessibility
  • Office hours of in-network providers

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HHS Promises to Complement State Standards

Now that adequacy reviews will be coming back under Federal oversight, HHS promised that the new standards will –

“Complement state standards while meeting Federal obligations,” and they intend to “coordinate closely with state authorities to address compliance issues, eliminate duplicative requirements or reviews, and reduce stakeholder burden.”

Time Will Tell on Telehealth

Telehealth is of special interest to HHS given its recent expansion during the COVID-19 pandemic. HHS intends to consider the role telemedicine services can play in meeting adequacy standards and will detail specific criteria and processes in future rulemaking.

Discover how telemedicine is changing traditional measures of network adequacy.

Provider Types Expanding

HHS could expand network adequacy to include behavioral health. They intend, “to evaluate QHP issuer networks for access to providers enrollees most generally use and/or that have historically been the subject of network adequacy concerns raised by patients and other stakeholders.”

Learn more about the changes coming to mental health and substance use disorder here.

Future Direction

There is still more to come, and you can count on us to closely monitor the progress. Be sure to stay tuned for more details!

Looking for more information on QHP Network Adequacy Reviews?

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