Consideration for Health Equity Measures in Network Adequacy Standards

The Affordable Care Act (ACA) directed the Centers for Medicare & Medicaid Services (CMS) to establish rules to require that Exchange health plans ensure a sufficient choice of providers.¹ To implement this requirement, CMS adopted quantitative standards, which require Exchange health plans to ensure that its network providers are available to members within specified time and distance measures.²  Taken together, these laws laid the initial foundation for what we know as network adequacy requirements that apply to Exchange health plans today. Since the passage of the ACA, both Congress and CMS have continued to build on network adequacy by adding more requirements with the goal of enhancing access to quality, affordable care through the Exchanges.³

In recent years, efforts to improve Exchange health plan responsiveness to the health equity status of its members have become a major area of focus. Health equity is generally understood to be a state in which every person has the opportunity to achieve their full health potential, and in which no person is disadvantaged because of social circumstances.⁴ In alignment with a recent Executive Order (EO)⁵, which established a government-wide approach to advancing equity, CMS is seeking input on methods to analyze data to inform future Exchange health plan network adequacy standards that impact health equity.⁶