NBPP 2024 Part 1: Network Adequacy & Essential Community Providers

The ACA includes a long list of codified instructions about what's required under the law, but many of the specific details are left up to the agency responsible for implementing it since the legal text itself can't possibly cover every conceivable detail involved. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS).

Each year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of tweaks to some of the specifics of how the ACA is actually implemented.

Yesterday CMS released their proposed 2024 NBPP, which includes some important changes which, if included in the final version, will go into effect starting next fall (for calendar year 2024). The full proposed 2024 NBPP is actually 370 pages long; yesterday I posted the press release & Fact Sheet. Today I'm breaking it down into smaller chunks since there's a lot to talk about here:

Network Adequacy:

CMS proposes to revise the network adequacy and essential community provider (ECP) standards to provide that all individual market qualified health plans (QHPs), including stand-alone dental plans (SADPs) and all Small Business Health Option Program (SHOP) plans across all Marketplace-types must use a network of providers that complies with the network adequacy and ECP standards in those sections, and to remove the exception that these sections do not apply to plans that do not use a provider network. Requiring that all QHPs use a provider network would better ensure consumer access to a sufficient choice of providers and would guarantee consumers have access to information on the availability of in-network providers.

For 2023, the final NBPP started requiring that CMS review healthcare provider network adequacy reviews in federal ACA exchange states based on time and distance standards; for example, at least one primary care physician has to be within a 10 minute drive and 5 miles of any enrollee in large metropolitan counties; starting in 2024, routine primary care appointments have to be available within 15 business days of being requested, and so forth.

For 2024, this proposed NBPP appears to be expanding the types of plans which are subject to these network adequacy rules to also include stand-alone dental plans, small group plans (SHOP) sold on the ACA exchange (several hundred thousand people are enrolled in these nationally, including 78,000 in California, 87,000 in the District of Columbia, 8,000 in New Hampshire).

Essential Community Providers:

CMS also proposes to expand access to care for low-income and medically underserved consumers by establishing two additional stand-alone ECP categories for Plan Year (PY) 2024 and beyond: 1) Mental Health Facilities; and, 2) Substance Use Disorder (SUD) Treatment Centers. Additionally, for PY2024, CMS proposes to retain the overall 35% provider participation threshold, and also extend the 35% threshold to two major ECP categories: Federally Qualified Health Centers (FQHCs); and, Family Planning Providers. These changes would increase provider choice and access to care for low-income and medically underserved consumers.

"Essential Community Providers" are defined by the Kaiser Family Foundat as:

...providers that serve predominantly low-income, medically underserved individuals, and specifically include providers described in section 340B of the Public Health Service (PHS) Act and the Social Security Act...

• Federally Qualified Health Centers (FQHCs) and FQHC "Look-Alike" clinics
• Ryan White HIV/AIDS Program Providers
• Family Planning Providers
• Indian Health Providers
• Hospitals
• Other ECP Providers including STD clinics, TB clinics, Hemophilia treatment centers, Black Lung clinics

The 35% threshold refers to the minimum percent of healthcare providers in the carrier network which have to provide services to these communities or organizations. It was raised from 20% to 35% for some of these for 2023; for 2024 they're adding mental health facilities and substance use disorder treatment centers to the list, and are applying the 35% threshold to two more of the ECP groups.