The Expanding Role of State-Based Exchanges in Network Adequacy

State-Based Exchanges (SBEs) are becoming increasingly important participants in network adequacy oversight, reflecting a broader shift toward more localized approaches to evaluating provider access. For years, network adequacy reviews have largely been governed by federal standards and state insurance department requirements. Increasingly, however, exchanges are playing a more active role in plan management, certification, data validation, and market oversight, positioning them as key stakeholders in how access to care is measured and monitored.

The final 2027 Notice of Benefit and Payment Parameters (NBPP) reinforces this trend. Through the Effective Provider Access Review Program (EPARP), CMS established a pathway for states to assume greater responsibility for provider access reviews in Federally Facilitated Exchange markets. While federal standards remain in place, the policy reflects growing confidence in state-level oversight and creates an opportunity for states to align network adequacy reviews more closely with local market realities, provider supply, and consumer needs.

Several mature SBEs offer a glimpse into what this evolution may look like. Covered California has long taken an active approach to plan management and certification, leveraging its marketplace authority to drive improvements in quality, consumer experience, and provider data accuracy. Washington Health Benefit Exchange and Connect for Health Colorado have similarly developed sophisticated plan management frameworks characterized by close coordination among exchanges, regulators, issuers, and other stakeholders. While these exchanges do not replace traditional regulatory oversight, they demonstrate how marketplace infrastructure can support a more engaged and data-driven approach to evaluating network performance.

The opportunity created by greater state involvement is significant. Provider access challenges are inherently local. Workforce shortages, specialist availability, rural access concerns, and market dynamics vary considerably across states and even within regions of the same state. A review methodology designed around national standards may not always capture those nuances. States are often better positioned to identify emerging access issues, incorporate local market knowledge, and adapt oversight approaches to reflect the realities facing consumers and providers.

At the same time, the value of increased state autonomy will ultimately depend on execution. The question is no longer whether states can play a larger role in network adequacy oversight; it is whether they can do so in a way that improves access while maintaining consistency, transparency, and accountability.

As states develop or expand provider access review programs, variation in methodologies is inevitable. Different approaches to provider file validation, appointment availability reviews, exception processes, and specialty access standards may emerge across markets. Some level of flexibility is appropriate and may even be desirable. However, without clear methodologies and consistent operational frameworks, increased state involvement risks creating variation in oversight without producing meaningful improvements in consumer access.

Reliable data will be equally important. Across the industry, provider directory inaccuracies, outdated participation records, and incomplete network submissions continue to challenge both regulators and issuers. As oversight becomes more sophisticated, the focus will increasingly shift from whether a network appears adequate on paper to whether data accurately reflects real-world access. States, exchanges, issuers, and technology partners will all play a role in building the infrastructure necessary to support that transition.

Ultimately, the expanding role of State-Based Exchanges presents an opportunity to move network adequacy oversight beyond compliance-driven reviews and toward a more practical assessment of consumer access. Mature exchanges have already demonstrated how active plan management, stakeholder engagement, and operational investment can strengthen oversight. The 2027 NBPP creates a framework for more states to build on those models. The challenge now is ensuring that increased flexibility is accompanied by the transparency, consistency, and data integrity necessary to translate oversight into improved access to care.

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