Network Adequacy Standards Strengthened for Plan Year 2015
Health plans participating in federally facilitated insurance exchanges may be subject to a higher standard of “network adequacy” in 2015 than prior years, according to draft guidance from the federal agency tasked with overseeing the exchanges.
The Affordable Care Act and subsequent regulatory guidance require qualified health plans participating in the exchanges to meet certain standards for the adequacy of their provider network, including maintaining a network of a sufficient number and type of providers that specialize in mental health and substance abuse services to ensure that services are available without an unreasonable delay. However, since the opening of the exchanges this year, behavioral health providers have expressed concern that they are being shut out of health plans’ networks.
The new draft guidance from the Center for Consumer Information and Insurance Oversight (CCIIO) proposes that health plans be required to submit a detailed provider list, which will be evaluated using a uniform “reasonable access” standard (see page 19 of the letter) focusing closely on providers that historically have raised concerns because they may not be included. These include hospital systems, mental health providers, primary care providers, and others. The letter also states that plans must contract with at least 30 percent of the “essential community providers” in their service area. Prior CCIIO guidance stated that although community mental health and addiction treatment providers do not fall under the definition of essential community providers, they may be counted as such for the purpose of plans’ meeting their network adequacy standards. It is unclear at this point whether or how the new draft letter changes this prior guidance.