Appointment Wait Time Network Adequacy Requirements for Qualified Health Plan Certification as stated in the 2025 Letter to Issuers

COMMISSIONER OF SECURITIES AND INSURANCE Troy Downing Office of the Commissioner Montana State Auditor ADDENDUM TO APRIL 10, 2024 ADVISORY MEMORANDUM To: ALL INTERESTED PERSONS From: TROY DOWNING Commissioner of Securities and Insurance, Montana State Auditor Date: April 16, 2024 Ref: Appointment Wait Time Network Adequacy Requirements for Qualified Health Plan Certification as stated in the 2025 Letter to Issuers The Office of the Montana State Auditor, Commissioner of Securities and Insurance (CSI), issues this Addendum to the Advisory Memorandum, dated April 10, 2024, titled 2025 Form, Rate, & Network Adequacy Filing Requirements Including Qualified Health Plan Certification (here, April 10 Advisory Memorandum). The April 10 Advisory Memorandum summarized provisions the 2025 Final Notice of Benefit Payment Parameters (2025 Final Rule) issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS), as well as proposed provisions in the 2025 Draft Letter to Issuers. Shortly after CSI issued the April 10 Advisory Memorandum, CMS issued the finalized 2025 Letter to Issuers (2025 Letter to Issuers). This Addendum briefly summarizes certain provisions of the 2025 Letter to Issuers related to appointment wait time network adequacy standards. Neither the April 10 Advisory Memorandum nor this Addendum exhaustively discuss QHP certification requirements, or all new requirements in the Final Rule or Letter to Issuers. Issuers should independently review the Final Rule, Letter to Issuers, and related publications. Please see the following links for specific information: 2025 Letter to Issuers: https://www.cms.gov/files/document/2025-letter-issuers.pdf 2025 Final Rule: https://www.federalregister.gov/documents/2024/04/15/2024- 07274/patient-protection-and-affordable-care-act-hhs-notice-ofbenefit-and-payment-parameters-for-2025 April 16, 2024 Page 2 840 Helena Avenue, Helena, Montana 59601 (main fax) 406.444.3413 I (securities fax) 406.444.5558 (insurance consumer services fax) 406.444.1980 I (legal fax) 406.444.3499 (phone) 800.332.6148 or 406.444.2040 I (email) csi@mt.gov I (web) www.csimt.gov As explained in the April 10 Advisory Memorandum, CMS delayed implementation of requirements finalized in the 2023 Final Notice of Benefit and Payment Parameters related to appointment wait time network adequacy standards to Plan Year (PY) 2025. The 2025 Letter to Issuers confirms that, beginning January 1, 2025, 45 CFR 156.230(a)(2)(i)(B) requires QHP issuers, including SADP issuers, in the FFEs to meet appointment wait time standards for primary care (routine), behavioral health, and specialty care (non-urgent) providers. These standards are established in Chapter 2, Section 3.ii.b of the 2023 Letter to Issuers, and reiterated in Chapter 2, Section 3.ii.b of the 2025 Letter to Issuers. In addition, the 2025 Letter to Issuers states that CMS will require medical QHP issuers offering QHPs in the FFEs to contract with a third-party entity to administer secret shopper surveys to meet appointment wait time standards. The secret shopper surveys are only required to be conducted for a QHP issuer’s primary care (routine) and behavioral health providers, the taxonomy codes for whom are provided in Tables 2.1 and 2.2 in the 2025 Letter to Issuers. (CMS is expecting to require secret shopper surveys for specialty care (non-urgent) providers in future plan years.) CMS stated it intends to release additional technical guidance to further describe secret shopper survey requirements in advance of PY2025. More details on the appointment wait time standards and secret shopper survey requirements are in Chapter 2, Section 3.ii.b of the 2025 Letter to Issuers. This advisory memorandum is informational only and does not enlarge, limit, or modify any requirements of applicable law or in any way limit the authority of CSI under applicable law. CSI encourages interested persons to consult with independent legal counsel for guidance on the application of law to any particular circumstances.