The U.S. Department of Health and Human Services (HHS) is accepting public comment on a Dec. 23 draft letter that provides operational and technical guidance to issuers of qualified health plans (QHPs) through the federally facilitated health insurance marketplace (FFM) for calendar year 2017.
The letter, from the HHS Center for Consumer Information and Insurance Oversight (CCIIO), details essential community provider (ECP) standards that are unchanged from 2016:
- Each QHP network must include at least 30 percent of all available ECPs in a service area.
- Each QHP must offer contracts to at least one ECP in each ECP category in each county of a service area and to all available Indian health providers in a service area.
- Contracts must offer terms comparable to those for a similarly situated, non-ECP provider.
- A QHP that cannot achieve 30 percent participation may still be certified if it provides a satisfactory narrative justification describing how the plan’s provider networks offer an adequate level of service for low-income and medically underserved enrollees; and how it plans to increase ECP participation in the future.
CCIIO also expands on network adequacy provisions in a Nov. 20 proposed rule outlining payment parameters and standards for insurance plans, including QHPs offered in health insurance marketplaces, CCIIO reiterates the proposal to have the Centers for Medicare & Medicaid Services (CMS) establish a process through which states would be responsible for selecting minimum network adequacy standards and reviewing QHPs in FFMs. CMS would evaluate a state’s standards to ensure use of quantifiable network adequacy metrics. CCIIO set the following acceptable metrics as a framework for reviews:
- prospective time and distance standards
- prospective minimum, provider-covered person ratios for “the specialties with the highest utilization rate for its state”
If CMS makes this proposal final, it will work with states to confirm state use of recognized metrics. CMS will not undertake network adequacy review of QHPs for certification in states conducting reviews. If a state does not review QHPs for network adequacy, or if the standards are not approved, the FFM would conduct its own review under a federal default standard, which would be a time and distance standard calculated at the county level.
Comments are due to CCIIO by Jan. 17. Questions? Contact Director of Policy Erin O’Malley at firstname.lastname@example.org or 202-585-0127.