Standards for Provider Network Adequacy in Medicaid and the Marketplaces

By Andy Schneider and Alexandra Corcoran, Georgetown University Center for Children and Families*

The Centers for Medicare & Medicaid Services (CMS) has issued final rules for provider network adequacy in Qualified Health Plans (QHPs) offering coverage in the marketplaces that the federal government operates through Under these rules, which come with the snappy title, “Notice of Benefit and Payment Parameters” and the even snappier initialism (NBPP), CMS will require QHP provider networks to meet minimum time-and-distance standards beginning in 2023 and minimum standards for appointment wait times beginning in 2024. The rules themselves do not specify the minimum standards; these come through separate guidance, which will allow CMS to strengthen the standards over time as it gets more operational experience. (CMS issued the minimum time-and-distance standards for 2023 on April 28).

“What does this marketplace rule have to do with Medicaid?” At this point, not much. But it should. And, under current CMS authority, it could.

In explaining its new requirements, CMS underscored the obvious: “… strong network adequacy standards are necessary to achieve greater equity in health care and enhance consumer access to quality, affordable care through the [marketplaces].”  The same applies to the other coverage programs that CMS administers—Medicare, Medicaid, and CHIP. In each of these programs, managed care plans are paid to organize provider networks to deliver covered services to beneficiaries. If the networks are not adequate, beneficiaries will have difficulty accessing the services they need. The starting point for access is the setting and enforcement of network adequacy standards.

With the support of the Robert Wood Johnson Foundation, we and our colleagues at the Center on Health Insurance Reforms (CHIR) recently compared the standards for network adequacy in Medicaid with those in the marketplaces. What we found was that, on paper, the standards for the adequacy of MCOs in Medicaid are stronger than those for QHPs in the marketplaces, even though the federal government is directly responsible for operating the majority of marketplaces while the states have day-to-day administrative responsibility in Medicaid. We did not evaluate the provider networks of individual MCOs or QHPs, so we don’t know the extent to which the networks are in fact adequate to ensure timely enrollee access to covered services. (An important analysis just published in Health Affairs found that, in a sample of four states, most (75 percent or more) of the primary and specialty care services received by Medicaid MCO enrollees were delivered by a small (25 percent)  proportion of the providers participating in the MCO networks, raising questions about the relationship of standards to actual access to providers.)

Under federal Medicaid regulations, state Medicaid agencies are responsible for developing, publicly posting, and enforcing a quantitative network adequacy standard for a minimum of seven different provider types: primary care physicians (PCPs) (adult and pediatric); OB/GYNs; behavioral health (mental health and substance use disorder), adult and pediatric; specialist, as defined by the State (adult and pediatric); hospital; pharmacy; and, pediatric dental. Quantitative standards can include metrics such as a cap on how far or for how long beneficiaries must travel to reach an in-network provider (time and distance standard), a minimum number of providers per beneficiaries in a service area (provider-to-enrollee ratio), or a maximum amount of time someone can be made to wait (appointment wait time standard).  States set their own standards; there are no federal minimums. Medicaid beneficiaries have the right to switch MCOs if the network is inadequate.

Under the federal marketplace regulations that were in effect at the time we did our research, QHP provider networks had to be “sufficient in number and types of providers…to assure that all services will be accessible without unreasonable delay.”  Not exactly quantitative. (As noted above, the new NBPP gives CMS the authority to issue guidance specifying minimum quantitative time-and-distance standards beginning with plan year 2023, which it has done).  In addition, QHP provider networks must include essential community providers (federal Medicaid regulations do not require the inclusion of ECPs). Unlike Medicaid beneficiaries, marketplace enrollees do not have the right to switch plans between open enrollment periods if they find their QHP’s network too narrow.

We looked at network adequacy standards in six states: Florida, Georgia, Kansas, New Mexico, Pennsylvania, and Washington. Students of Medicaid will not be surprised to learn that we found wide variation from state to state in the robustness of the network adequacy standards. Interestingly, however, we also found significant variation between the Medicaid and marketplace standards within the same state. For example, all six of the states we studied mandated that MCOs meet specific time and distance standards for PCPs, OB/GYNs, and mental health providers, but only three (FL, NM, and PA) included quantitative standards for all of these providers on the marketplace side. Even when states established quantitative standards for both MCOs and QHPs, they were often quite different. For example, in Washington, Medicaid MCO enrollees in urban areas must have at least two PCPs within ten miles with a travel time no greater than 90 minutes on public transportation while 80 percent of QHP consumers must have a “sufficient” number of PCPs within 30 miles of their residence or work.

CMS issuance of the NBPP for 2023 lays the regulatory groundwork for the imposition of minimum quantitative network adequacy standards for all QHPs in the 30 states on the federally facilitated marketplace. In doing so, it may flip the script on which program offers more consistent beneficiary protections across states. Case in point: Table 3.2 of the CMS guidance for 2023 specifies minimum time-and-distance standards for individual providers in 34 different specialties (ranging from Allergy and Immunology to Vascular Surgery) in each of five different types of counties (Large Metro, Metro, Micro, Rural, and Counties with Extreme Access Considerations). In the case of primary care, for example, at least 90 percent of adult enrollees in a Large Metro County would have to have reasonable access to at least one primary care provider within 10 minutes and 5 miles; in a Rural County, within 40 minutes or 30 miles.

The new rule is not without its limitations. The minimum standards that CMS has issued for 2023 and will issue for 2024 will not apply to the QHP networks in the 21 states that operate their own marketplaces; the state-based marketplaces are free to apply their own standards, which can be more or less robust than the CMS minimums. And even in the states where the CMS minimums apply, if a QHP’s network doesn’t meet the minimum standard, the marketplace can allow the QHP to participate if doing so is “in the interests of” marketplace consumers. Finally, there’s the matter of monitoring and enforcing QHP compliance with the standards when exceptions are not granted. Still, the imposition of minimum quantitative network adequacy standards for QHPs marks a major step forward in efforts to improve consumer access to care in the federally facilitated marketplace.

Medicaid beneficiaries deserve the same protections against inadequate provider networks. CMS can and should establish minimum quantitative standards for Medicaid MCO provider networks that are at least as stringent as those that CMS applies to QHPs in the federally facilitated marketplace. In states that currently have standards lower than those that CMS adopts for the marketplaces it operates, the extension of those marketplace standards to Medicaid can improve access for MCO enrollees.  And, given the ongoing movement of beneficiaries between Medicaid and the marketplace due to income fluctuations—movement that will likely be exacerbated when the COVID-19 Public Health Emergency ends—the alignment of the minimum standards for QHP and MCO provider networks will help reduce disruptions of access to care due to network discontinuities.

The adoption of minimum quantitative standards for network adequacy in managed care would require a change in current Medicaid regulations. On its way out the door, the prior administration weakened those regulations. CMS can correct that mistake and “achieve greater equity in health care and enhance access to quality, affordable care through Medicaid managed care.” Let the rulemaking begin!

*Editor’s Note: This blog was originally published on the Center for Children and Families’ Say Ahhh! Blog. It has been edited slightly for publication on CHIRblog.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.