Network Adequacy

About a week and a half ago I received the following email (posted w/permission w/identity removed):

Hello Mr Gaba. Last year I had a BCBS insurance through marketplace and this year I switched to a Physicians Health Plan offering, also through the marketplace. I thought I had done due diligence. I was interested in switching to the University of Michigan system. As I shopped for plans the PHP website listed literally hundreds of potential pcp's near me in Ann Arbor. But as I began to try and sign up with a new doctor and called the number listed for each doc (usually the same U-M switchboard number) I found that none of the docs listed were, in fact, accepting new patients.

At the moment I cannot find a new pcp through my new health insurance. Is this legal? Have I any recourse? Where can I find info on what to do? They suggest that I try to get my former doctor to fill out a prior approval or out of network form...Hoping you can direct me to somewhere; thank you for any direction you can offer me.

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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: