“It’s incumbent upon health plans to think through: how are we creating new linkages with our providers? How can we more quickly and seamlessly encourage our provider network to better manage patients, allow members to have a better understanding of their options, and better longitudinally manage their care?”
— Nick Bluhm, JD, Vice President of Legal & Regulatory
As state and federal regulators ramp up efforts to enhance the transparency of behavioral health care, Qualified Health Plans (QHPs) and health care providers face an evolving landscape. The focus on improving access and quality of care for behavioral health services is stronger than ever. Understanding and complying with new rules and regulations is critical to ensure seamless care access for members.
In a recent webinar, Nick Bluhm, Lucet’s VP of Legal and Regulatory Affairs, delved into the nuances of these regulatory changes and provided valuable insights to help plans navigate these complexities.
“Regulators are of the mind that beyond simple network adequacy, there needs to be more transparency around disclosing status, decision results and clinical basis for prior authorization.”
Nick Bluhm, JD – Vice President of Legal & Regulatory
Appointment wait time requirements for Qualified Health Plans
Regulators are going beyond statutes like the Mental Health Parity and Addiction Equity Act of 2008, which emphasized comparability without setting specific standards. The Centers for Medicare & Medicaid Services (CMS) and the Center for Consumer Information and Insurance Operations (CCIIO) are relying on other authorities to establish minimum standards for plans, covering benefits offered, financial requirements, and the financial responsibilities of the plan relative to the member for covered services.
Recently, issued guidance on interoperability and prior authorization, which are part of medical management and add requirements for transparency. This includes increased clarity about the information used in administering benefits and how it is communicated.
One of the pivotal aspects of the new regulations is the enforcement of appointment wait time requirements by the CCIIO. Regulators are concerned that more than half of members in Qualified Health Plans are either new to that plan or new to the Exchange Marketplace. Members may not have readily observable information to understand network quality, as well as how providers can best manage their and their dependents’ health.
CMS expects QHPs operating in Federally Facilitated Exchanges to adhere to these requirements to ensure timely access to care. Behavioral health appointment wait times must be 10 business days or less, primary care appointment wait times must be 15 business days or less, and specialty care appointment wait times must be 30 business days or less.
Secret Shopper Survey requirements
To comply with CMS and auditor mandates for appointment wait time reporting, plans must develop a robust methodology for accurately measuring appointment wait times and ensuring members receive timely care.
Plans are required to contract with a third-party secret shopper to conduct surveys during January–May 2025. The secret shoppers will contact a sample of providers from a CMS-provided pool to ask about the first available appointments for primary care or behavioral health needs, both in-person and via telehealth. The providers included in the survey sample are based on those listed in the network adequacy file submitted to CMS as part of the QHP certification. Notably, this methodology will be proportional—that is, the number of providers the secret shoppers need to survey will be proportional to the network size.
In June 2025, the issuer will submit appointment wait time survey results as part of the QHP certification.
Transparency for both Qualified Health Plans and providers
The federal government is elevating the standards for issuers and health care providers to share information about the care received by beneficiaries. Prior Authorization rules and Information Blocking are two such rules aimed at democratizing access to data for care and medical management. First, CMS expects QHPs to be more transparent with providers and members in several areas: sharing electronic health information upon request by the member or treating provider, and disclosing status, decision results, and the clinical basis for prior authorization decisions.
Recently, the Department of Health and Human Services (HHS) finalized its information blocking rule, creating “disincentives” for health care providers who engage in practices that interfere with the use of electronic health information. The HHS Office of the Inspector General intends to focus on information blocking practices that:
- Caused or may cause harm to patients
- Impedes the ability of health care practitioners to care for patients
- Resulted in losses to the Federal Health Care Programs
- Were done with actual knowledge
Beyond formal regulations, sub-regulatory developments can also influence how plans operate. The anticipated sub-regulatory changes are expected to be issued this calendar year and will help plans stay ahead of the curve and proactively adapt to new requirements.
Action steps for plans
As the regulatory landscape for behavioral health continues to evolve, staying informed and prepared is crucial for plans aiming to deliver high-quality care to their members. Nick Bluhm encourages QHPs to take the following steps to best prepare to meet these enhanced expectations in this new landscape:
- Review data sources: Identify and address gaps in your technology infrastructure for managing member experiences.
- Create a roadmap: Plan how your enterprise will share and obtain workflow and clinical information.
- Embrace transparency: Anticipate how to administer benefits in an environment with increased regulatory scrutiny.
Reach out to [email protected] for more information on how Lucet can help your plan meet these new regulatory challenges head-on.
Nick Bluhm, JD is vice president of legal and regulatory and Britta Nordstrom is a senior marketing specialist at Lucet, The Behavioral Health Optimization Company.
