New ACA Adequacy Rule Expands Access but Means Big Changes for Health Insurers

The final ACA Network Guidance expands health care accessibility for consumers, but the majority of plans will have to play catch up to get into compliance. J2 Health research found that 80% of existing plans are currently out of compliance and will need to make big network changes for PY 2023.

On April 28th, CCIIO - the CMS body that regulates the Affordable Care Act (ACA) - finalized its Plan Year (PY) 2023 network adequacy requirements. The new guidance, the first change since 2017, redefines network adequacy for all plans sold in the 33 Federally Facilitated Marketplace states.

Plans will need to meet stricter standards in order to receive CMS approval.

In the new regulations, plans must provide reasonable access to care for 47 speciality types, a significant increase from the previous requirement of 10 specialities.

J2 Health, a network optimization and analytics platform, reviewed over 250 carrier networks provided to CMS for PY 2022, and found that 80% of networks did not meet new network adequacy requirements. The average network failed to meet 15% of the required county-specialty pairs. In some states, provider networks were failing 30% of the requirements.

Over the next several years, J2 expects these regulations to have a large impact on the individual market. To stay in compliance, health insurers will need to rapidly broaden and expand their networks. For consumers in ACA plans, access to care will expand nationwide. The impact on payer-provider negotiations, plan offerings, and premiums will be fascinating to watch. More to come from J2 on how we see this dynamic playing out.

About J2

J2 Health provides the technology for healthcare organizations to build their best provider networks and deliver higher value healthcare. Our network adequacy solution provides customers a clear and trusted path to compliance, while minimizing impact to their overall network strategy.