CMS finalizes QHP provider network requirements for 2016

The Centers for Medicare & Medicaid Services Friday released a final letter to insurers describing 2016 certification requirements for Qualified Health Plans in federally-facilitated marketplaces or the Small Business Health Options program. Like the draft letter, the final letter requires QHPs with provider networks to maintain a network that is sufficient in number and types of providers, including those providing mental health and substance abuse services, to assure that all services will be accessible to enrollees without unreasonable delay. CMS said it will evaluate QHP networks to ensure adequacy and use what it finds to help articulate network adequacy standards in future rulemaking. To determine whether an issuer meets the “reasonable access” standard, CMS said it “will focus most closely on those areas which have historically raised network adequacy concerns,” which may include hospital systems, mental health providers, oncology providers, primary care and dental providers. As in 2015, CMS said issuers applying to certify a QHP for plan years beginning in 2016 will be required to demonstrate that at least 30% of available Essential Community Providers in its service area participate in its provider network. The ECP hospital category includes Disproportionate Share Hospitals and DSH-eligible hospitals, children’s hospitals, Rural Referral Centers, Sole Community Hospitals, Free-standing Cancer Centers and Critical Access Hospitals. Also Friday, the Office of Personnel Management issued a final rule amending certain standards related to coverage area, benefits and contracting provisions for insurers that contract with OPM to offer Multi-State Plan options under the Affordable Care Act.