The Final 2015 Letter establishes a new standard to measure provider network adequacy and creates a more stringent standard for the inclusion of essential community providers such as hospitals that serve low-income patients.
"CMS will now be assessing provider networks with a 'reasonable access' standard in order to figure out which networks failed to provide access 'without unreasonable delay,'" says Gregory Hammond, a legal analyst at the Health Reform KnowlEdge Center in Riverview, IL.
For the 2014 plan year, CMS assessed provider network adequacy based on three criteria: carrier accreditation status, a state review that was at least as stringent as reviews required under federal law, and network access plans collected from carriers.
In their formal comments filed Feb. 25, AHIP officials urged CMS not to change the provider network adequacy criteria: "First, the proposed changes are a significant and unnecessary departure from how network adequacy is reviewed today. Second, we are very concerned that such significant changes and rulemaking are being considered so close to the beginning of the application submission process. Third, we believe CMS' approach will be practically difficult—if not impossible—to implement, particularly for the 2015 benefit year." The AHIP officials say developing a provider network "can take upward of a year or more to complete."