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Posted by on Feb 17, 2015 in Uncategorized | 0 comments

Six things insurers are saying about HHS’s proposed network adequacy rule

Six things insurers are saying about HHS’s proposed network adequacy rule

Issuers Voice Concerns Regarding Proposed Network Adequacy Standards

In November 2014 the U.S. Department of Health & Human Services released a Proposed Rule, Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2016[1], that addresses a variety of issues related to the PPACA and QHP issuers; one of the most contentious is network adequacy. Here is a quick summary of the notice as it relates to network adequacy rules that apply to QHPs using a provider network:

  • A provider network includes only providers that are contracted as in-network; out-of-network providers will not be counted for purposes of network adequacy.
  • The NAIC has formed a workgroup that is drafting a model act relative to network adequacy; HHS will await the results of this workgroup before proposing significant changes to network adequacy policy.
  • For 2016, HHS expects to continue to use the reasonable access standard adopted in the 2015 Letter to Issuers in the FFM.
  • HHS encourages QHP issuers that use a network to offer new enrollees transitional care for an ongoing course of treatment and they are considering whether requirements are needed in this area.
  • HHS proposes requiring QHP issuers to publish an up-to-date, accurate, and complete provider directory (including specific data elements) and make that directory easily accessible to multiple stakeholders. As part of this requirement, HHS proposes requiring QHP issuers to update directory information at least once a month.
  • HHS is considering requiring issuers to make directory information publicly available on their Web sites in a machine-readable file and format specified by HHS in order to provide an opportunity for third parties to aggregate the information and increase transparency.
  • HHS acknowledges that issuers may incur “minor administrative costs” associated with updating their provider directory to comply with new requirements.

HHS sought comment on the proposed rule; these comments are available for viewing by the public[2]. Through these comments, several narratives emerged that underscored the insurer community’s sentiment to the proposed rule.

  1. The need for up-to-date provider directories was recognized by many issuers. CMS was encouraged to take into account the responsibility for keeping provider information up-to-date should be shared by both insurers and providers, as insurers rely on providers to keep information current.
  2. HHS’s decision to await the result of the National Association of Insurance Commissioners (NAIC) workgroup drafting a model act relative to network adequacy was supported. HHS was encouraged to heed the NAIC’s guidance.
  3. Many issuers believe states are best positioned to develop standards that should apply to the insurance markets in their state. It was recommended that HHS support the state’s role in this process by providing states with the flexibility to develop criteria that fits the specific market of their state.
  4. It was recommended HHS allow adequate time for changes to be made to provider contracts.
  5. Several issuers believe that HHS is underestimating the costs associated with implementing changes.
  6. The payor community supports transparency and understands the need for consumer-facing tools, but is concerned that machine-readable files, as used by third-parties, will not effectively provide meaningful information to consumers because:
    • Insurers make constant updates to provider directory data, meaning it would be difficult for a tool to provide the most up-to-date and accurate information
    • There are no uniform standards to ensure integrity and accuracy of information
    • Proper protections are not in place around the release of competitive information to ensure accurate information is used to provide consumers access to directory information.

Network adequacy will continue to be in the spotlight in the coming years as new standards are developed to fit the changing healthcare landscape. Access to information, specifically provider information, will continue to be a key concern as more individuals obtain health insurance and seek access to care.


[1] Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2016

[2] Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2016: Comments

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Strenuus has a range of software and data solutions centered on the management of healthcare provider data. This expertise has made it the go-to resource for a variety of industry stakeholders who need actionable information about provider networks. In addition to Strenuus’ role supporting network optimization efforts for payors, it has become the backbone for integrated search solutions for exchanges and online directories.

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