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CMS Releases Draft Letter to 2018 QHP Issuers

The Department of Health and Human Services (HHS) has released a draft letter that provides operational and technical guidance to issuers of qualified health plans (QHPs) through the federally facilitated health insurance marketplace for calendar year 2018.

The letter, from the HHS Center for Consumer Information and Insurance Oversight (CCIIO), details essential community provider (ECP) standards that are unchanged from 2017:

  • 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; and
  • 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.

CCIIO reiterates that, as in prior years and in the 2018 Notice of Benefit and Payment Parameters proposed rule, the Centers for Medicare & Medicaid Services (CMS) will assess whether QHP provider networks meet the reasonable access standard using these 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.”

QHP networks that do not meet time and distance standards criteria can submit detailed information to CMS that demonstrates how they provide reasonable access to enrollees through a justification process.

Comments are due to CCIIO by Dec. 1 and should be sent to FFEcomments@cms.hhs.gov. Contact Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.

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