NBPP 2023 Part 2: Network Adequacy!

The Affordable Care Act includes a long list of codified instructions about what's required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.

While the PPACA is itself a lengthy document, it would have to be several times longer yet in order to cover every conceivable detail involved in operating the ACA exchanges, Medicaid expansion and so forth. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS)

Every year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of tweaks to some of the specifics of how the ACA is actually implemented.

This morning, CMS issued the final NBPP for the upcoming 2023 Open Enrollment Period. Since there's so many provisions included, this year I've decided to break it into multiple posts which only focus on one or a few of them at a time:

(Note: QHP = Qualified Health Plan...basically, an ACA-compliant major medical policy available on an ACA exchange.)

Implementing New Network Adequacy Requirements

The rule helps ensure that patients have access to the right provider, at the right time, in an accessible location. The rule requires QHPs on the Federally-facilitated Marketplace (FFM) to ensure that certain classes of providers are available within required time and distance parameters. For example, a QHP on the FFM will be required to ensure that its provider network includes a primary care provider within ten minutes and five miles for enrollees in a large metro county. The rule also sets a standard, starting in the 2024 plan year, requiring QHPs on HeathCare.gov to ensure that providers meet minimum appointment wait time standards. For example, QHPs will be required to ensure that routine primary care appointments are available within 15 business days of  an enrollee’s request. Additionally, HHS will review additional specialties for time (i.e., the time it takes the enrollee to get an appointment) and distance (i.e., the distance between the provider and enrollee) – including emergency medicine, outpatient clinical behavioral health, pediatric primary care, and urgent care. OB/GYN parameters will also be aligned with the parameters for primary care. 

Additional details from the Fact Sheet:

CMS finalizes changes such that CMS will conduct network adequacy reviews in all states with a FFM except for states performing plan management functions that adhere to a standard as stringent as the federal standard and elect to perform their own reviews. Beginning for plan year (PY) 2023, CMS will evaluate QHPs for compliance with quantitative network adequacy standards based on time and distance standards. Beginning for PY 2024, CMS will also evaluate QHPs for compliance with appointment wait time standards. These reviews will occur prospectively during the QHP certification process. Issuers that are unable to meet the specified standards would be able to submit a justification to explain why they are not meeting the standards, what they are doing to work towards meeting them, and how they are protecting consumers in the meantime. CMS also finalizes a requirement that QHPs submit information on whether providers participating in their network offer services through telehealth.

Additionally, HHS will review additional specialties for time and distance that are necessary to meet the unique health care needs of QHPs enrollees, such as emergency medicine, outpatient clinical behavioral health, pediatric primary care, and urgent care. OB/GYN parameters will also be aligned with the parameters for primary care. 

This is one of the most important improvements they can make...and is also likely to be one of the most difficult to enforce properly. It's one thing to say that carriers have to have PCPs within five miles of everyone living in their coverage area; it's something else to actually make that happen.

The risk, besides making sure to actively confirm that all carriers are in compliance (which has to be a major task, I'd imagine), is that some carriers which are unable or unwilling to comply with the new network rules will bail entirely.

Of course, that's not necessarily a bad thing--while more competition is usually regarded as a positive, it's not helpful to have a bunch of policies where the closest in-network hospital is three hours away cluttering up the exchange.