Exchange / QHP Network Requirements: What Issuers Need to Know

The ACA Section 1311 Foundation

Qualified Health Plan (QHP) network adequacy requirements are grounded in Section 1311(c)(1)(B) of the Affordable Care Act, which requires that QHPs maintain "a 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." CMS operationalizes this requirement through its QHP certification standards, which are updated annually for each open enrollment cycle.

For issuers selling on the Federally Facilitated Marketplace (FFM), CMS directly reviews network adequacy as part of the QHP certification process. For issuers on State-Based Marketplaces (SBMs), the state exchange authority reviews adequacy using its own standards — which may be more or less stringent than the federal floor.

CMS QHP Certification Network Standards

For FFM issuers, the CMS QHP certification checklist includes:

• Time-and-distance standards for at least 30 provider specialty types, applied at the county level using the same general methodology as MA adequacy
• Quantitative standards (provider-to-enrollee ratios) for several high-demand specialties
• Telehealth integration requirements — unlike MA where telehealth flexibility is being reduced, QHP standards have formalized telehealth as an acceptable modality for certain specialties
• Provider directory accuracy certification — issuers must attest that their provider directory is accurate within the past 30 days of submission
• Network access plan — a narrative document describing how the plan ensures member access to services when in-network providers are unavailable

Essential Community Providers (ECPs)

One of the most distinctive QHP requirements — with no direct MA equivalent — is the Essential Community Provider (ECP) requirement. ACA Section 1311(c)(1)(C) requires that QHPs include sufficient ECPs in their networks. ECPs are providers that serve predominantly low-income, medically underserved populations, and the category includes:

• FQHCs and FQHC Look-Alikes
• Ryan White HIV/AIDS Program providers
• Family planning providers (including Planned Parenthood affiliates that accept marketplace patients)
• Indian Health Service providers
• State-designated ECP providers

CMS sets an annual ECP threshold — typically requiring issuers to include a minimum percentage of available ECPs in each county. For 2025, the threshold is 35% of available ECPs in each plan's service area. Issuers who cannot meet this threshold must submit a narrative justification explaining good-faith outreach efforts.

SBM vs. FFM: Key Variations

State-Based Marketplaces have authority to set network standards that exceed the federal floor, and many do. Notable variations include:

• California (Covered California) requires specific provider-to-enrollee ratios that are more stringent than federal standards and conducts independent network adequacy reviews using secret shopper appointment surveys
• New York and Massachusetts apply enhanced behavioral health parity standards that require issuers to demonstrate comparable access to mental health services as physical health services
• Several SBM states require quarterly network adequacy monitoring and reporting rather than annual certification

Annual Filing Timeline for Open Enrollment

QHP certification runs on a compressed timeline tied to the November 1 open enrollment launch:

• February–March: CMS publishes draft QHP certification requirements for comment
• May: Final QHP certification requirements published
• May–June: Issuers submit initial QHP applications including network data
• July–August: CMS reviews and issues deficiency notices
• August–September: Issuers respond to deficiencies and resubmit
• October: Final certification decisions issued
• November 1: Open enrollment launches