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Posted by on Jan 25, 2016 in Uncategorized | 0 comments

Proposed Rule Focuses on Provider Networks

Proposed Rule Focuses on Provider Networks

In November 2015, 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 2017[1], that addressed a variety of issues related to the PPACA and issuers participating on the Federally-Facilitated Exchanges or Marketplaces (FFM). Provider networks continue to be in the limelight with HHS dedicating a large section of the Proposed Rule to the topic and the issuer community commenting heavily on the subject in response.

Below, you will find a quick summary of the notice as it relates to provider network rules that apply to Qualified Health Plans (QHPs) and Stand Alone Dental Plans (SADPs). HHS sought comments on this rule; these comments can be viewed by the public by visiting These comments reveal several narratives that underscore the issuer community’s sentiment toward the Proposed Rule.

Standardized Option


The Proposed Rule includes a section introducing a Standardized Option. This section proposes to establish a specific standard set of bronze, silver (with CSR variations), and gold plans in the individual market FFMs in order to simplify the consumers’ ability to compare plans and make informed choices. These standardized plan designs would include only a single provider network tier.


Many issuers voiced concerns that the introduction of a standardized option would stifle competition among issuers, inhibit innovation in plan design, and limit consumer options, which will in turn limit affordable, accessible health care.

Standardized designs include only a single in-network tier; with many issuers utilizing innovative, multi-tier products to reduce costs, many current product designs would require substantial re-working to meet the proposed requirements of the standardized options. If CMS moves forward with this rule, it is recommended that they include a tiered network design.

While this was the majority sentiment, several issuers commented in support of the Standardized Options and testified to their ability to allow for comparisons across issuers and networks, and thus, improve consumer plan selection.

In the dental industry, which has not experienced the narrowing of networks like what we have seen with medical networks, issuers feel that this type of oversight is unnecessary and that CMS should recognize that when it comes to network adequacy, dental plans are different from major medical plans.

Network Adequacy Standards


The Proposed Rule includes several sections related to network adequacy; setting network adequacy standards is key to this proposal. In states in which a FFM is operating, FFMs would rely on state reviews for network adequacy, provided that the state uses an acceptable network adequacy metric. In states that do not review for network adequacy, or do not meet the standard to be developed by HHS, HHS proposes to determine network adequacy standards and anticipates including at the least a:

  • review based on time and distance standards
  • minimum provider-covered person ratios


Last year, issuers supported the HHS decision to await the result of the National Association of Insurance Commissioners (NAIC) workgroup drafting a model act relative to network adequacy. Many issuers believe states are best positioned to develop standards that should apply to the insurance markets in their state.

Now that the NAIC has completed its work on the Network Adequacy Model Act, following a significant period of discussion including many key stakeholders, issuers have emphasized their position by opposing federal requirements regarding network adequacy and continuing to recommend that HHS follow this model act which relies on individual states to set standards that are appropriate for their unique markets.

Notice of Discontinuation of Provider


The Proposed Rule looks to establish a requirement that QHP issuers in all FFMs make a good faith effort to provide written notice of a discontinued provider, 30 days prior to the effective date of the change or otherwise as soon as practicable, to all enrollees who are patients seen on a regular basis by the provider or receive primary care from the provider whose contract is being discontinued.


CMS was encouraged to take into account the responsibility of providers in ensuring patients have the information they need to receive care. It was recommended that CMS encourage providers to give their patients notice of a decision to discontinue in a network, rather than putting the burden on the issuer.

There were also concerns around the meaning of the vague phrase “regular basis,” which would be especially difficult to define in the dental space.

Issuers emphasized the fact that the NAIC Model Act addresses this issue and that this situation should be covered by states’ network adequacy standards; HHS should defer to the states.

Network Breadth Classification


The Proposed Rule includes a section that aims to establish a standardized categorization of network depth, or strength, for QHPs that would be displayed to consumers making a plan selection on HHS anticipates analyzing provider networks by calculating the number of providers that are accessible within specified time and distance standards and then assigning a classification from one of three categories.


Many issuers do not believe that adding a “Network Coverage Rating,” based on the number of providers within a certain time and distance, to will provide meaningful or useful information for consumers. Presenting network information in this manner is essentially saying that broader is better – rather than looking at the quality of the network. Many voiced concerns that this rating would be misleading and confusing for consumers.

If CMS decides to move forward with this rule, it is recommended that they provide an in-depth comment period and solicit input from issuers.

Provider Networks in the Spotlight

Provider networks will continue to be in the spotlight in the coming years as new standards are developed to fit the changing healthcare landscape. The push from regulators to move to more standardized plan options makes the provider network more important than ever before. Access to information, specifically provider information, will continue to be a key concern as more individuals obtain health insurance and seek access to care.

If you are a health plan and would like to know more about how Strenuus can help, please email



[1] Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2017

[2] Patient Protection and Affordable Care Act: HHS Notice of Benefit and Payment Parameters for 2017: Comments

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