Issuers in all Federally Facilitated Exchange state, including those operating in states that have elected to perform review must submit their Network Adequacy data in the Essential Community Provider (ECP) & Network Adequacy (NA) Template for review and approval.
KEY PY 2024 CHANGES
All individual Market Qualified Health Plans (QHP) including Small Business Health Option Program (SHOP) and Stand Alone Dental Plans (SADP), must meet NA and ECP standards. Exceptions where meeting this standard is “prohibitively difficult” may be granted to SADPs but SADPs only.
ECP standards now include two (2) additional categories: 1) Mental Health Facilities, 2) Substance Use Disorder (SUD) Treatment Centers. The 35% ECP provider participation threshold introduce in PY 2023 will continue and extend beyond the threshold to two (2) categories: Federally Qualified Health Centers (FQHCs) and Family Planning Providers.
Note: Centers for Consumer Information and Insurance Oversight (CCIIO) and the Department of Health and Human Services (HHS) have noted questions and concerns that plans have submitted with regards to the Appointment Wait Time (AWT) standards introduced in PY 2023 NBPP. The two offices will work together to release additional clarifying guidance, especially around accuracy and methodology.
SUBMISSION PROCESS
The Review Process NA and ECP templates for PY 2024 will mirror that of PY 2023. Issuers must meet the 90% reasonable access standards for the listed speciality types. The PY 2024 Template has been updated and now allows users to link the ECP/NA providers to its associated networks. In order for a provider to count towards adequacy scoring, the provider must be licensed and offer in-person services. Issuers can seek a network exception in instances where they do not meet adequacy standards by submitting the NA/ECP Justification Form via the Project Management (PM) Community.
For additional detail, consult the following tools made available by CMS.
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