Sec. 301. Network adequacy requirements
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/bill/115/s/2582/is/section-301·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1311(c) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031(c) ) is amended— in paragraph (1)(B), by inserting and paragraph
(7)and in accordance with paragraph
(8)after Public Health Service Act ; and by adding at the end the following: A qualified health plan shall meet the network adequacy standards established by the Secretary under subparagraph (B), except as provided in subparagraphs (B)(ii) and (C). The Secretary shall establish a network adequacy standard based on access to in-network providers for qualified health plans, except for those plans described in subparagraph (C). Such standard shall include requirements for the minimum number and type of in-network providers available, the geographical location of such providers, the average distance and travel time required for patients to visit such providers, and the average appointment wait times for services covered by the plan. The network adequacy standard established under subclause
(I)shall, at a minimum, be equivalent to the requirements for access to services applicable to Medicare Advantage organizations offering Medicare Advantage plans under part C of title XVIII of the Social Security Act. A qualified health plan that fails to meet the standard established under clause
(i)may satisfy the requirement under subparagraph
(A)by providing the Secretary with a reasonable justification for the variance from such standard, based on factors such as the availability of providers and variables reflected in local patterns of health care. The Secretary shall establish a process for reviewing the network adequacy of qualified health plans, except for those plans reviewed by the State in accordance with subparagraph (C)(ii). In the case of a qualified health plan offered in a State that has implemented a quantifiable network adequacy metric that the Secretary determines is an acceptable metric commonly used in the health insurance industry to measure network adequacy, such qualified health plan may satisfy the requirement under subparagraph
(A)by meeting the network adequacy standards of such State based on such metric. A State with an acceptable metric described in clause
(i)may review the network adequacy of qualified health plans offered in such State in a process established by the State. A qualified health plan shall provide, to an individual enrolled in such plan, coverage of any service provided by an out-of-network provider if— coverage of such service would otherwise be provided by the plan if the service was provided by an in-network provider; the service is included in the essential health benefits package described in section 1302(a); and the service cannot be provided to the individual by an in-network provider within a reasonable timeframe or within a reasonable distance and travel time. A qualified health plan that provides coverage of a service provided by an out-of-network provider under subparagraph
(A)shall provide such coverage with the same cost-sharing requirements as if the service was provided by an in-network provider. . The amendments made by subsection
(a)shall apply to plans beginning after December 31, 2019. The Secretary of Health and Human Services shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2020 to assist such States in developing a metric to measure network adequacy as described in subparagraph (C)(i) of section 1311(c)(7) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031(c)(7) ) and to carry out the reviews described in subparagraph (C)(ii) of such section. There are authorized to be appropriated for fiscal years 2020 through 2024 such sums as may be necessary to carry out the grant program under this subsection.
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Sec. 301
Network adequacy requirements
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