Network Adequacy Standards For QHPs And More Guidance For 2023

Network Adequacy Standards For QHPs And More Guidance For 2023

January 12, 2022 0 By administrator

Although 2022 has just begun, HHS is already preparing for the 2023 plan year. On December 28, the Department of Health and Human Services (HHS) issued its proposed 2023 notice of benefit and payment parameters, which is summarized in three parts here, here, and here. Since then, HHS has issued complementary materials related to the 2023 plan year. This includes the draft letter to insurers in the federally facilitated exchange (FFE) and the actuarial value (AV) calculator and methodology. The draft letter to issuers is of particular note because it includes proposed substantive standards for network adequacy for the 2023 plan year. HHS previously released guidance with the proposed key dates for calendar year 2022, the proposed qualified health plan certification timeline, and the proposed rate review timeline; these timelines are also summarized here.

Draft Letter To Issuers

The annual “letter to issuers” provides operational and technical guidance for issuers that offer qualified health plans (QHPs) or stand-alone dental plans through the FFE. Many of the standards outlined in the letter apply equally to QHPs sold inside and outside of the marketplaces in the individual and small group markets. Comments on the draft letter are due by January 27 (the same deadline for comments on the proposed 2023 payment notice).

The most significant issue in the 2023 draft letter is its proposed substantive standards for network adequacy. As discussed more here, HHS proposed resuming its own evaluation of the adequacy of provider networks for QHPs offered through the FFEs and would adopt quantitative time and distance standards and appointment wait-time standards. In the preamble to the proposed rule, HHS noted that the actual parameters for both sets of standards would be detailed in further guidance. The draft letter to issuers is that further guidance.

HHS also details its expectations for collecting information from insurers about whether in-network providers are offering telehealth services or not. For these purposes, telehealth is defined as “professional consultations, office visits, and office psychiatry services through brief communication technology-based service/virtual check-in, remote evaluation of pre-recorded patient information, and inter-professional internet consultation.” HHS also proposes a new pilot program that would measure and publicly display the breadth of a QHP’s network on

Time And Distance Standards

HHS’s approach to time and distance standards would generally align with that of Medicare Advantage, with counties classified into five designations (e.g., large metro, micro, rural, etc.). The draft letter then includes charts with the proposed maximum time and distance standards for each county type based on provider specialty types.

HHS will review insurer-submitted network data to ensure that each plan provides access to at least one provider in each of the provider-type categories for at…

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