ACP Calls for CMS to Ensure Network Adequacy in the ACA Proposed Rule for 2025

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Says plans through the Marketplaces should meet network adequacy requirements to ensure services are accessible without unreasonable delay

Feb. 9, 2024 (ACP) -- The American College of Physicians is urging federal officials to strengthen regulations regarding "network adequacy" -- the matter of whether "provider" networks offered by health plans are sufficient to allow patients to reasonably seek and find care.

"ACP strongly believes that all patients should have access to a personal physician," Dr. Omar T. Atiq, president of ACP, wrote in a Jan. 8 letter to Xavier Becerra, secretary of the U.S. Department of Health and Human Services. "Therefore, exceptions to network adequacy requirements should be strictly limited."

At issue are federal plans to update regulations regarding certain health plans for 2025. The provisions will mainly affect Qualified Health Plans on the Health Insurance Marketplaces, but they will also impact Medicaid, the Children's Health Insurance Program and the Basic Health Plan.

These regulation updates are routine and affect the workings of "provider" networks, how cost-sharing is structured, how insurance companies and brokers are regulated, the benefits and services that plans must offer and much more, according to Ryan Crowley, ACP senior associate for health policy.

"ACP has been a strong advocate of the Affordable Care Act, and health insurance regulation is important for patients and physicians alike," Crowley said. "Millions of people purchase coverage through the Marketplaces. A record 21.3 million got Marketplace-based coverage during the most recent open enrollment period."

ACP is especially concerned about network adequacy. "Plans offered through the Marketplaces have to meet certain network-adequacy standards that ensure there is a sufficient number and types of health care professionals so services are accessible without unreasonable delay," Crowley explained. "A lot of plans have developed networks with a narrow selection of physicians and other clinicians."

As Crowley explained, "Health coverage isn't useful if you can't access your preferred physician. Patients may pay higher cost-sharing if their physician is out of network, and if it's too expensive, they may delay care or go without it altogether. Some plans won't cover non-emergency out-of-network care at all."

ACP has called for strong quantitative standards to ensure networks are adequate. In recent years, the Centers for Medicare & Medicaid Services has strengthened the standards for the federal marketplace, Crowley explained. Now, they propose to extend the requirements to state-based exchanges.

In the Jan. 8 letter, Atiq wrote that "issuers unable to meet network adequacy requirements must undergo a thorough justification process in which they clearly articulate why they cannot meet network adequacy requirements."

He added, "If an exception is sought due to a shortage of available physicians in an area, an issuer should be required to submit data to support the veracity of the claim, such as shortage designation information from the Health Resources and Services Administration. Issuers should describe what actions they've already taken to contract with an area physician by, for example, increasing reimbursement rates, reducing administrative burdens and onerous utilization management processes and making investments in primary care."

In addition, ACP encourages regulators "to regularly track and fix network deficiencies and 'provider' directory errors as they occur through the Essential Community Providers and Network Adequacy Post-Certification Compliance Monitoring program or other processes," Atiq wrote.

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Back to the February 9, 2024 issue of ACP Advocate