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Washington Highlights

HHS Releases Exchange Establishment Final Rule

March 16, 2012—The Department of Health and Human Services (HHS) March 12 released the final rule on the Establishment of Exchanges and Qualified Health Plans and Exchange Standards for Employers, implementing the new Affordable Insurance Exchanges (“exchanges”) created under the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152).  This rule provides the framework enabling states to build an exchange and the standards for eligibility for enrollment in qualified health plans (QHPs) and insurance affordability programs.

The AAMC commented on the proposed rule, specifically focusing on the proposals relating to exchange plan network adequacy and essential community providers for the networks established by QHPs [see Washington Highlights, Oct. 7, 2011]. HHS proposed only requiring that a QHP must include a provider network with “a sufficient choice of providers for enrollees” and “a sufficient number of essential community providers, where available, that serve predominately low-income, medically-underserved individuals.” HHS also proposed to define essential community providers as including only those groups suggested in the ACA, namely those named in section 340B(a)(4) of the Public Health Service Act and in section 1927(c)(1)(D)(i)(IV) of the Social Security Act.

The final rule contains few changes to either of these provisions.  HHS did not add any additional providers to the definition of essential community providers, so the definition remains limited to all health providers in the proposed rule. The AAMC believes that many of its members will qualify under this criterion. However, the department did offer one modification clarifying that any provider that meets the criteria for an essential community provider, or met the criteria on the publication date of this regulation, must be considered an essential community provider.

The language about network adequacy has been modified slightly to clarify that a QHP issuer must maintain a “provider network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.” Lastly, HHS offered a clarification that a QHP issuer may not be prohibited from contracting with any essential community provider.

The rule will be published in the Federal Register on March 27; nine provisions of the rule are being released as an interim final rule with a 45-day comment period.


Jane Eilbacher
Policy and Regulatory Specialist
Telephone: 202-828-0896


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Telephone: 202-903-0806