Final rule for Affordable Care Act marketplace plans could expand contracting opportunities for certain types of providers in 2024

Final 2024 regulations for health plans participating in the Affordable Care Act (ACA) insurance marketplaces are designed to improve equitable access to behavioral healthcare, potentially meaning a wider array of providers will have a chance to be included in networks.

As of 2023, a participating plan must have at least 35% of available essential community providers (ECPs) in its network, according to regulations previously published by the U.S. Department of Health and Human Services (HHS). The plan must negotiate in good faith to contract with at least one provider in each of the ECP categories (assuming any such provider is in the plan’s service area):

• Inpatient hospitals
• Federally qualified health centers (FQHCs)
• Ryan White Program providers
• Family planning providers
• Indian health providers
• Other ECP providers

The inpatient hospital category specifically refers to disproportionate share hospitals, children’s hospitals, rural referral centers, sole community hospitals, freestanding cancer centers and critical access hospitals.

In 2024, the list of ECP types will expand to include two new categories:

• Mental health facilities
• Substance use disorder treatment centers

Those facilities previously have been included in the miscellaneous “Other” category, out of which plans must seek to contract with only one provider type to satisfy regulatory requirements.

In another tweak, the 35% participation threshold for ECPs is expanding to apply specifically to both FQHCs and family planning providers.

Rural emergency hospitals, a designation that began this year in the Medicare program, will be part of the “Other ECP” category, joining rural health clinics, black lung clinics, hemophilia treatment centers, sexually transmitted disease clinics and tuberculosis clinics.

For 2023, a record 16.3 million people signed up for coverage through the ACA’s 30 federally facilitated marketplaces and 21 (including Washington, D.C.) state-run marketplaces. Open enrollment for 2024 spans Nov. 1-Dec. 15.

Delay of a key requirement

Regulations for 2023 set time-and-distance standards for provider networks, ensuring enrollees a certain level of care access. The ’23 rule also established that beginning in 2024, ACA plans in the federally facilitated marketplaces would have to attest to their compliance with wait-time standards.

However, in the newly published final rule, that requirement has been postponed to 2025.

In submitted comments on the looming proposal, stakeholders “highlighted the need for HHS to issue additional guidance necessary for [health insurance] issuers to comply with appointment wait-time standards and to allow the industry time to comment on that guidance,” the final rule states. “Many commenters noted the lack of specificity around how appointment wait times would be assessed and how issuers could attest without a standard metric.”

The burden on providers to report data to insurers also was among the concerns, as were the operational challenges for insurers in monitoring contracted providers.

The rule also states that the one-year delay “will allow HHS to ensure that these wait-time standards are implemented in a holistic, logical way across [federal] programs.”

Specific guidelines for complying will be released in later guidance.