Reform Alert - News from the Blues' Office of National Health Reform

Network Adequacy and Essential Community Providers

July 9, 2012

The Exchange final rule (PDF) issued on March 27, 2012 establishes minimum criteria for network adequacy in order for products to be certified as QHPs. For example, a QHP issuer must ensure that the provider network meets all of the following standards:

  • Includes essential community providers
  • Maintains a network that is sufficient in number and types of providers
  • All services will be accessible without unreasonable delay*

In addition, a QHP issuer must make its provider directory available for online publication on the Exchange, as well as to potential enrollees in hard copy upon request.

What data is required in the provider directory?

The Department of Health and Human Services expects provider directories to include the following information on each provider:

  • Licensure or credentials
  • Specialty
  • Contact information including institutional affiliation

The Exchange may establish additional data elements that QHP issuers must include. Further, the Exchange has discretion regarding the inclusion of non-physician providers in a provider directory. If included, the directory should identify the services the provider is contracted to perform by displaying such providers only when consumers search for specific services.

HHS encourages Exchanges to consolidate QHP provider directories, although it is not required.

Provider directories must meet all of the general standards for Exchange notices, including accommodations for individuals with limited English proficiency and/or disabilities.

What if a provider is no longer accepting new patients?

Provider directories must identify providers that are not accepting new patients.

How will provider directories be updated?

The Exchange final rule does not include guidelines on how often a provider directory must be updated. Rather, the rule suggests Exchanges consider a balance between consumer choice and the burden on issuers to comply.

What is an essential community provider?

Essential community providers are providers who serve predominately low-income, medically underserved individuals, including, but not limited to, FQHCs, urban Indian organizations, and public or non-profit community hospitals.

Section 156.235 of the Exchange final rule states a QHP issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of providers for low-income, medically underserved individuals in the QHP's service area.

Are Mental Health and Substance Abuse services included?

Mental health and substance abuse services were specifically included to recognize that essential health benefits will create additional demand for these services, and QHP issuers will be required to provide sufficient access.

How will Essential Community Providers be reimbursed?

The Exchange final rule does not establish specific payment rates for essential community providers. Rather, the rule states a QHP issuer is not required to contract with an essential community provider if such provider refuses to accept the issuer's generally applicable payment rate (at a minimum, the rate offered to similarly situated providers who are not essential community providers).

Contracting with Indian Providers?

To make it easier for QHP issuers to contract with Indian providers, HHS intends to develop a template for contracting purposes. While use of the template will not be mandated, Exchanges could elect to direct QHP issuers to use the Standard Indian Addendum when contracting with Indian providers.

What is BCBSM doing?

BCBSM will need to ensure its QHPs meet all network adequacy requirements, including the inclusion of essential community providers. BCBSM will be required to develop and provide a provider directory to the Exchange for its QHPs.

BCBSM will continue to monitor the provisions and will update as needed. 

* The final rule does not define an expectation as to what constitutes an unreasonable delay. Rather, the narrative explains that such decision was designed to provide flexibility and compatibility with existing state regulation and oversight.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.