Rural Considerations in Establishing Network Adequacy Standards for Qualified Health Plans in State and Regional Health Insurance Exchanges

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, authored by research staff at the Maine Rural Health Research Center, USM Muskie School, examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access.

The authors review ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models, and 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. The authors propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers, including 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.

Suggested Citation: Talbot, J. A., Coburn, A., Croll, Z. and Ziller, E. (2013), Rural Considerations in Establishing Network Adequacy Standards for Qualified Health Plans in State and Regional Health Insurance Exchanges. The Journal of Rural Health. doi: 10.1111/jrh.12012