Rural Considerations in Establishing Network Adequacy Standards for Qualified Health Plans in State and Regional Health Insurance Exchanges
Funding: We received funding from the State Health Access Reform Evaluation (SHARE): A program of the Robert Wood Johnson Foundation, Grant # 68077. Karen B. Pearson, MLIS, of the Muskie School of Public Service contributed research support for this article. Catherine Au-Yeung, MPH, of SHARE reviewed and commented on an earlier draft of the manuscript.
For further information, contact: Jean A. Talbot, PhD, 65 Berkeley St., Portland, ME 04103; e-mail: firstname.lastname@example.org.
The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access.
This policy analysis reviews ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models. We analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. Finally, we propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers.
A traditional approach to safeguarding rural access is to impose strict network adequacy standards on plans in rural areas. However, if strict standards prove difficult to meet due to rural provider scarcity, they might diminish QHPs' willingness to serve rural areas. Thus, they could exacerbate rather than alleviate rural access problems.
To benefit rural communities, network adequacy standards must be strong enough to provide real protections for beneficiaries, yet flexible enough to accommodate rural delivery system constraints and remain attainable for QHPs. Useful strategies to achieve this balance might include: adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.