Health Reform: Network Adequacy Standards

For QHP certification, a plan must have an adequate provider network available to its enrollees. A QHP must:

  • Offer a network with a sufficient number of providers, including mental health and substance abuse providers, to ensure access to all services without unreasonable delay
  • Include a sufficient number and geographic distribution of essential community providers to ensure reasonable and timely access to care for low-income and medically under-served populations in the QHP’s service area


glitch girl ipad reformThe Marketplaces offer only health insurance plans that are certified as qualified health plans, or QHPs. These QHPs must be licensed and meet certain transparency requirements. To become certified, a QHP must meet a minimum set of criteria, including:

  • Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits (EHB).
  • Benefit design standards, including non-discrimination requirements and limits on cost-sharing
  • Network adequacy standards

Each QHP issuer must offer a Silver level and a Gold level QHP in a Marketplace. These requirements became effective as of January 1, 2014


Questions about healthcare coverage under the affordable care act? Contact your Total Benefit Solutions ACA specialist at (215)355-2121 or toll free at (800)924-6718.