Issue Briefs | Aug 11, 2013

ACA Implications for State Network Adequacy Standards

Georgetown University Health Policy Institute – Sally McCarty and Max Farris

This brief, prepared by the Georgetown University Health Policy Institute, explores some of the discrepancies that can arise with varying network adequacy standards and provides examples of how some states have resolved such issues. Network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract.

States have taken different approaches in regulating the adequacy of health plan networks based on their state-specific market. States have a variety of options available to maintain robust health insurance markets by balancing access needs with the goals of controlling costs and attracting a healthy number of insurers. Appendix A serves as a comparison table of different network adequacy standards and requirements.  Appendix B provides a narrative description of network adequacy standards in California, Colorado, Delaware, Hawaii, Maryland, Minnesota, Montana, Texas, Vermont, Washington, and the Federally-facilitated Marketplace.

 

 


Expert Perspectives

December 1, 2023

The Proposed 2025 Notice of Benefit and Payment Parameters: Implications for States

On November 15, 2023, the Centers for Medicare & Medicaid Services released its proposed 2025 Notice of Benefit and Payment Parameters, the annual regulation which governs core provisions of the Affordable Care Act. This expert perspective focuses on aspects of the proposed rule likely to be of interest to state officials, including requirements for State-Based Marketplaces to align with the standards of the Federally Facilitated Marketplace, proposals for states to update essential health benefits, and initiatives to ease the eligibility and enrollment process for consumers.

CMS Releases Information Bulletin on Coverage of Services and Supports to Address Health-Related Social Needs in Medicaid

This expert perspective summarizes CMS’ new Informational Bulletin and accompanying framework which together detail Medicaid coverage options for services that address the health-related social needs (HRSN) of Medicaid enrollees. The new guidance reiterates the importance of addressing HRSNs to improve access to care and health outcomes, and summarizes (and in some cases updates) multiple previous sources of CMS guidance on how HRSN services may be covered in Medicaid, including guidance on in lieu of services authority and on HRSN coverage in section 1115 waivers.