CMS says it will defer to states for network adequacy standards

Following criticism from the health insurance industry, the federal government has dialed back portions of its proposed rule that would more strictly regulate health plans' network adequacy at the federal level.

In the final version of its 2017 Notice of Benefit and Payment Parameters, the Centers for Medicare & Medicaid Services (CMS) sets forth a host of regulations that govern health plans operating on the Affordable Care Act exchanges. Among these are controls on plans' provider networks that it tweaked in response to comments from industry stakeholders.

The commenters had raised concerns about aspects of CMS' proposed rule, which included federal default standards for network adequacy that they say were not included in National Association of Insurance Commissioners' draft of a model state law. America's Health Insurance Plans had urged the agency to "defer to the expertise of state insurance regulators on network adequacy to assure consumer choice of high-quality coverage options, including high-value and tiered network plans."

So CMS says it will give states time to adopt NAIC's proposals, which it notes all states and the District of Columbia have approved and that the NAIC hopes to adopt within three years.

"We note our expectation that all states, including [federally facilitated exchange] states, will actively implement these provisions, and we look forward to monitoring states' progress this year, with a particular view to avoiding duplicative federal and state review processes," the final rule says.

The final rule, however, will still take steps to monitor network adequacy. For example, CMS wants plans, starting in 2017, to include a rating of each qualified health plan's relative network coverage based on the breadth of other plan networks available in a geographic area. CMS will also require insurers to take certain actions that ensure continuity of care for enrollees if a provider is terminated from a network, as well as take steps starting in 2018 to limit "surprise" out-of-network bills for consumers.

The final version of CMS' reforms also settles the open enrollment period for the 2017 and 2018 benefit years; codifies a marketplace model for states that want to start relying on's platform for their enrollment functions; and standardizes cost-sharing structures on marketplace plans, among other regulations.

To learn more:
- here's the final rule
- read CMS' fact sheet

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