CMS Finalizes ACA Network Adequacy Rule

An article from

Dive Brief:

• The Biden administration on Tuesday finalized new network adequacy standards for plans in state-run Affordable Care Act exchanges — and allowed states to add dental services as an essential health benefit.
• Starting in 2026, provider network standards that apply to federal marketplaces, like minimum time and distance standards for a variety of specialties, will also apply to state-based exchanges.
• The rule also requires states’ open enrollment periods to match that of the federal exchanges.

Dive Insight:

The adequacy of plans’ provider networks is key for members actually being able to access care covered by their health insurance plan. States and the federal government oversee the networks in the ACA marketplaces, but enforcement has been lax, critics and researchers say.

According to a government watchdog report, 243 out of 375 plan issuers on the federal exchanges didn’t comply with network adequacy standards for the 2023 plan year. States have reported similar issues, with officials telling the Government Accountability Office that health insurers weren’t meeting time and distance standards meant to ensure providers are geographically accessible to members.

Now, the CMS is applying those standards to plans sold by state exchanges. The standards will be calculated on a county-by-county basis, and apply to a variety of provider specialties, as they do in the federal exchanges, the CHS said in a fact sheet on the final rule.

Regulators left the door open to exceptions based on factors like the availability of providers in a market. Many plans have said a shortage of providers — especially in rural areas — makes it difficult for them to maintain comprehensive networks.

CMS initially proposed making these changes starting next year, before pushing back that deadline to 2026 in the final rule.

The regulation also allows states to include some routine dental care as a covered essential health benefit, including cleanings and diagnostic x-rays, starting in 2027.

It also makes changes to the enrollment period for states, including extending the special period for enrollment for low-income families and requiring marketplaces to hold open enrollment from November 1 to January 15.