Strengthening Federal Network Adequacy Requirements for ACA Marketplace Plans

Introduction and summary

The United States is grappling with a maternal health crisis:1 Black and American Indian/Alaska Native women are around three times more likely than their white peers to die from pregnancy-related complications.2 As policymakers continue efforts to expand health insurance coverage under the Affordable Care Act (ACA), federal regulators must ensure that marketplace plans meet the needs of all enrollees—including the roughly 7.2 million women of reproductive age, generally defined as ages 15 to 493—particularly given that Black women have seen strong gains in coverage in recent months.4 It is imperative that regulators equip ACA marketplace plans to serve all enrollees and connect patients with high-quality maternity care.

Black and American Indian/Alaska Native women are around three times more likely than their white peers to die from pregnancy-related complications.

One way to do this is by strengthening network adequacy requirements for managed care plans—insurance plans that contract with a specified network of providers to offer care to their enrollees at lower costs. The ACA requires managed care plans to maintain networks with adequate mixes of providers who deliver care and services under ACA-compliant qualified health plans (QHPs). This requirement is known as “network adequacy,”5 and regulators set minimum criteria for adequacy at the federal level.

What are network adequacy requirements?

Network adequacy requirements, enacted as an original provision of the ACA, are standards—developed and enforced by federal and state administrators—that govern the network of providers with whom a health insurance plan may contract in order to provide services at lower rates to consumers.

Network adequacy requirements ensure that health plans offer people meaningful access to care—care that is timely, of high quality, and culturally competent and that provides access to a diverse array of specialties. In essence, these standards ensure that people who purchase an insurance plan that uses a provider network can count on that network to meet their needs. Without these standards, health plans can elect to contract with a provider network that does not provide meaningful care, forcing patients to seek out-of-network services at a higher cost or forgo care altogether.

Network adequacy standards were significantly weakened under the Trump administration, which issued guidance in 2017 that shifted oversight and enforcement of these standards to the states.6 The Biden administration recently signaled its interest in undoing some of this damage as well as further strengthening the standards.

In a proposed rule published December 28, 2021, as well as in a follow-up draft letter sent to issuers in the federally facilitated exchanges in early January 2022,7 the administration proposed several important changes that are likely to bolster maternal health care on ACA exchanges. Most notably, the administration proposed to evaluate QHPs’ compliance with network adequacy standards based on time and distance standards and appointment wait-time standards as well as to collect from QHPs information on whether providers participating in their network offer telehealth services.8

Regardless of the final rule, however, moving forward, federal regulators must set robust standards that take a comprehensive view of maternal health care, including the need for:

  1. Minimum quantitative standards, including geographic access standards, provider-to-enrollee ratios applicable to OB-GYNs, and maximum allowable wait times for maternity care. While the proposed rules and guidance address the need for such standards, the U.S. Department of Health and Human Services should take care to ensure the proposed ratios are responsive to the needs of those seeking maternal health care.
  2. Additional provider and birthing support worker categories, which would compel plans to include midwives, doulas, lactation support consultants, and a range of essential community providers (ECPs), who play a critical role in the provision of maternity care.
  3. Increased access to alternative care modalities, facilitated by requiring that networks include providers with after-hours, 24/7, and telehealth availability. The administration’s proposal to collect some of this information signals an important step forward, but additional work in this space is needed.
  4. Comprehensive accessibility standards, including to ensure providers and birthing support workers are equipped to meet the needs of all patients.
  5. Improved provider directory guidance, which would ensure that directories are administered effectively and that they contain comprehensive provider information.

By adopting the standards outlined above, federal regulators will help to ensure that people are able to access a robust maternity care provider network and see improved maternal health outcomes. At a time when the United States is facing a maternal mortality crisis, strengthening managed care plans’ network adequacy requirements is needed more urgently than ever.

The proposed rule would address the current patchwork of plan standards

ACA statutes require only that plans have a sufficient provider network, and current regulatory guidance adopted during the Trump administration interpreting this requirement states simply that networks must be “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.”9 The statute also requires that plan networks include “essential community providers,” which it defines as health centers—including federally qualified health centers, Ryan White clinics, and family planning providers—that primarily provide care to low-income individuals living in areas with a shortage of health professionals.10

A note about this report’s recommendations

This report primarily discusses network adequacy standards in the context of maternal health, but policymakers could apply many of its recommendations more broadly to improve access to care for all patients insured through QHPs. For example, minimum quantitative standards for provider-to-patient ratios and geographic access could also be developed for nonobstetric services, such as primary and mental health care. And alternative care modalities, such as telehealth and after-hours care, could be employed across the care continuum.

This report’s recommendations are also well positioned to positively affect care for patients who are part of marginalized communities or who have diverse social identities. Regardless of pregnancy or parenting status, comprehensive accessibility standards help mitigate barriers to care for patients with disabilities and limited English proficiency (LEP), and improved provider directory guidance can ensure that patients, such as those from the LGBTQI+ community and from diverse racial and ethnic backgrounds, are able to identify providers with whom they feel most comfortable.

Absent finalization of the administration’s proposed rule, states have the discretion to determine whether provider networks available within QHPs are truly sufficient for their residents. This is largely due to policies enacted under the Trump administration—and it means that the level of oversight and the quality of standards vary greatly across the nation.

In the current landscape of patchwork plan standards, there is the potential for pregnant and postpartum patients in certain states to face unnecessary barriers to care.

This issue highlights the need for the administration to reengage on network adequacy, both in general and for maternal health specifically. In the current landscape of patchwork plan standards, there is the potential for pregnant and postpartum patients in certain states to face unnecessary barriers to care, including shortages of in-network obstetric providers and other perinatal health professionals; excessive wait times for prenatal and postpartum appointments; and difficulty finding clinics with accessible hours, adequate physical infrastructure, and language accommodations. While in some areas, provider shortages can significantly hamper efforts to improve network quality, it is nonetheless crucial to begin the process of improving access to care by setting uniform standards informed by patient needs.


This section discusses steps that federal regulators can take to address the maternal care crisis in the United States, highlighting state examples of existing comprehensive network adequacy guidelines that can provide a model for strengthening QHP network standards.

1. Set minimum quantitative standards

The National Association of Insurance Commissioners, which provides guidance to state agencies tasked with regulating insurance,11 has encouraged states to adopt quantitative standards to assess network adequacy12—many of which also appear in the administration’s proposals. Such standards include, among other measures: 1) geographic access standards requiring that certain providers are available within a reasonable distance of enrollees’ homes and workplaces; 2) certain provider-to-patient ratios to ensure a sufficient number of providers are available within a plan network to serve enrollees; and 3) wait-time limits aimed at ensuring that enrollees are not required to wait longer than a given interval between when they request and receive various forms of care. These standards could lead to improved access to maternity care, given that commonly reported barriers include travel distance and availability of prompt appointments.13

Several states have adopted quantitative standards to enable provider networks to deliver adequate care. Nine states—Colorado, Delaware, Illinois, Maryland, Missouri, New Hampshire, New Jersey, South Carolina, and West Virginia—outline specific geographic access standards to ensure that enrollees are not required to travel long distances when seeking OB-GYN care.14 Many of these states further delineate between access requirements in highly populated areas such as large cities, where access may be required within as few as 5 miles of enrollees’ homes, and less-populated areas such as rural communities, where access standards may allow a travel distance of up to 60 miles or more from enrollees’ residences.15 In addition to geographic access standards, Colorado, Illinois, Maryland, and West Virginia set explicit provider-to-enrollee ratios for OB-GYNs, ranging from one provider per every 1,000 enrollees to one provider per every 2,500 enrollees.16 Finally, Colorado, Delaware, and Missouri limit allowable wait times for obstetric visits: Colorado requires care to be available within seven calendar days of a request, and Delaware and Missouri further differentiate wait times by trimester, with allowable wait times ranging from three to 21 calendar days post-request.17

While these state-specific quantitative standards work toward increasing the availability and accessibility of maternity care providers in QHPs, the Biden administration’s newly proposed standards governing geographic access and provider-to-patient ratios for OB-GYNs, as well as wait-time limits for maternity care, are a critical step forward.

2. Increase provider and birthing support worker categories

Traditional maternity and obstetric providers, such as OB-GYNs, family medicine physicians, and labor and delivery nurses, are critical partners in the effort to reduce maternal morbidity and mortality. However, a truly comprehensive approach to improving maternal health must also draw on more community-based and holistically oriented providers and support workers, including midwives, doulas, lactation support staff, and ECPs.

Research has long demonstrated that midwives … are an invaluable resource in the effort to reduce maternal mortality and morbidity.


Research has long demonstrated that midwives—providers who, through a mix of training and experience, have developed expertise in delivering patient-centered pregnancy care18—are an invaluable resource in the effort to reduce maternal mortality and morbidity.19 In light of the strong evidence for the value of midwifery care, leading maternal health experts 20 have called for the expanded use of midwives as part of a multipronged approach to addressing disparities in maternal health outcomes.21 Several states, including Delaware, Maine, New Hampshire, New Jersey, New Mexico, New York, and West Virginia, either support or require network plans to include nurse midwives22 as available providers of prenatal and maternity care services.23 Moreover, plan networks should include community-based midwives in particular, given that they are expert maternal health providers and frequently come from the communities they serve, particularly Black and Indigenous communities.


Doulas can work and function in myriad ways, but at their core, they are lay individuals who are equipped with the knowledge and skills to support pregnant people before, during, and after birth.24 Doula support is associated with significant improvements in maternal health outcomes, including higher breastfeeding initiation rates, fewer low birth weight babies, and lower rates of cesarean sections.25 What’s more, people who worked with doulas during their birthing process reported improved well-being, reduced stress, and increased confidence in parenting.26 In recognition of the potential for doulas to improve maternal health, some state Medicaid programs have begun providing reimbursement for doula care.27 Following this example, QHPs could be required to include doulas and other similar community-based birth support workers in their provider networks to ensure access for pregnant enrollees.

Lactation support

Lactation support can similarly help people who have recently given birth to feel more comfortable and confident when choosing to breastfeed their new baby.28 Indeed, lactation support is associated with increased breastfeeding for medically vulnerable infants29 for whom feeding is a critical concern. Several types of providers are equipped to provide lactation support, including lactation consultants, counselors, and educators.30 Network adequacy requirements could facilitate access to lactation support by, for example, including network requirements to contract with lactation support workers as well as timely access requirements, such as limits on wait times, to ensure parents can access guidance around lactation without delay after giving birth.

Essential community providers

ECPs,31 who furnish a significant proportion of the care they provide to low-income or otherwise underserved populations, can be a lifeline for patients who might otherwise struggle to access or afford care. To participate in a federally facilitated ACA marketplace, plans currently must contract with 20 percent or more of the available ECPs within the area they service, although the federal government updates this standard annually.32 Some states choose to exceed federally defined standards. Minnesota, for example, identifies as ECPs licensed birth centers,33 which research has suggested may be particularly well positioned to provide and advance equitable and culturally sensitive maternity care.34 Arkansas, Georgia, Louisiana, Minnesota, South Carolina, and Washington state35 also go beyond the federal requirements to explicitly mandate inclusion of rural clinics and hospitals as ECPs, which has the potential to combat disparate maternity outcomes for pregnant people living in rural areas.36 Finally, several states, including Colorado, Maryland, Montana, and Washington, require plans to include some or all available ECP types in QHPs at a higher percentage than the current federal threshold.37

Federal network adequacy standards should require that QHPs include the full range of holistic and community-based maternity care providers within their network.

While some states have taken steps toward ensuring that provider networks include the full complement of maternal health providers, there is more work to do. Despite the extensive body of research demonstrating the efficacy38 of birth workers such as midwives, doulas, and lactation support workers, most states have not acted to ensure QHP networks include these groups. In addition to birth workers, certain providers such as birthing centers and rural clinics are uniquely positioned to reach people in their communities. Federal network adequacy standards should require that QHPs include the full range of holistic and community-based maternity care providers within their network.

Figure 1

3. Increase access to alternative care modalities

Including the right number, distribution, and types of providers in a network is necessary but insufficient to ensure true, equitable access to care. Comprehensive access is achieved only when care is available to patients at times and in modalities that fit their needs.39 States currently take several approaches to ensure that care is available to patients at times that fit their schedules and that plans account for unexpected or emergent maternity care needs. California sets high standards for after-hours access to nonemergent care, requiring that plans make such care available either during evening hours, until 10:00 p.m., and/or on weekends, for at least four hours on Saturdays.40 Illinois and Virginia require plans to ensure patients can access in-network telephonic or in-person clinical support 24/7.41 And in acknowledgment of constraints on patients’ time, Florida requires that in-network providers begin consultation with patients no later than one hour after the patient’s scheduled appointment time.42

Offering flexible hours and keeping appointments on time can help ensure access for patients who may otherwise struggle to make it to, and stay for, appointments due to barriers such as lack of child care or paid time off from work. The administration’s proposal to collect this information is a step in the right direction.

In order to ensure patients can access a truly adequate network of maternity care, providers must accommodate the scheduling and logistical needs and constraints of patients who want and need to see medical professionals in person.

Similarly, encouraging or requiring provider networks to offer telehealth services—as Arizona, Delaware, Hawaii, Illinois, Maryland, Michigan and New Hampshire do43—can make care easier to access for patients who lack structural supports such as paid time off or reliable transportation. However, states should not use telehealth options to supplant the requirements for availability of in-person care. In order to ensure patients can access a truly adequate network of maternity care, providers must accommodate the scheduling and logistical needs and constraints of patients who want and need to see medical professionals in person. To that end, federal network adequacy standards ought to require, or at least encourage, that QHPs include maternity care providers with both after-hours and telehealth availability.

4. Set comprehensive accessibility standards

Health care providers and facilities must also be equipped to meet the needs of diverse patient populations. Studies have shown that pregnant people with physical and intellectual disabilities44 and with limited English proficiency45 experience disparities in maternal health care—increasing the need for providers equipped to meet their unique needs. Similarly, pregnant people who are part of the LGBTQ community—12 percent of whom have had to teach their doctor how to provide their care, according to a CAP study from June 202046—and from diverse cultural and racial/ethnic backgrounds deserve the opportunity to connect with network providers who are comfortable and competent in providing care to the full range of pregnant and parenting people.

States vary widely in their provisions to ensure that networks can adequately care for patients with diverse needs. Pennsylvania requires that providers are “physically accessible to people with disabilities … [and] can communicate with individuals with sensory disabilities,”47 while Virginia stipulates that plans must employ strategies to ensure providers are accessible to people with “physical [or] mental” disabilities,48 and California requires that providers are “reasonably accessible” to patients with disabilities.49 Providers in New Mexico must afford patients who are deaf access to interpreter services,50 and Montana requires that providers have “appropriate and sufficient personnel, physical resources and equipment” to care for patients with disabilities.51 Moving forward, it is critical that network adequacy standards incorporate such provisions to facilitate the development of networks that are equipped to meet the needs of people at all levels of ability.

To account for the needs of patients with LEP, California, Montana, New Mexico, and New York explicitly require that plans and providers make interpreter services readily available for patients who speak languages other than English.52 Several states also hold providers accountable for their care of patients from different backgrounds: New York providers must dispense “culturally and linguistically competent care,”53 and New Mexico provider networks must share any guidelines or trainings used to educate providers regarding the “cultural and linguistic needs” of plan enrollees.54

To ensure that patients with disabilities, with LEP, and with diverse cultural backgrounds and identities can connect with providers positioned to meet their needs, federal network adequacy standards should articulate concrete guidance for network provider accessibility.

To ensure that patients with disabilities, with LEP, and with diverse cultural backgrounds and identities can connect with providers positioned to meet their needs, federal network adequacy standards should articulate concrete guidance for network provider accessibility, such as those developed by the U.S. Access Board specifying accessibility standards for medical equipment.55 Such standards could include those governing the physical accessibility of provider offices, provider collaboration with interpreter services, and requirements for cultural competency trainings that would equip providers with the tools to appropriately engage with patients from all racial, ethnic, and linguistic backgrounds and who identify as LGBTQI+, disabled, or as otherwise part of historically marginalized communities, among others.

Figure 2

5. Improve provider directory guidance

Provider directories, which often serve as the access point for patients seeking in-network care, also have an important role to play in ensuring that patients can locate and engage with providers equipped to meet their needs. Broadly speaking, directories should 1) be updated regularly, as at least 31 states require;56 2) indicate whether providers are accepting new patients, as at least 29 states require;57 and 3) be equipped with functionality to search and/or filter results, as at least 20 states require.58 Moreover, all enrollees would benefit from increased implementation of network breadth ratings, which assess the proportion of available providers included in a plan’s network across three specialty areas: primary care physician adult, primary care physician pediatric, and general acute care hospital.59 Plans could require these ratings as a component of their provider directories, and all states, not just those with previous rating pilots, could expand their plans to include ratings requirements and OB-GYNs and/or other obstetric providers as assessed specialties.

A handful of states have adopted additional specific standards to ensure that directories account for patients’ differing preferences, abilities, and linguistic backgrounds. Illinois and Washington state require directories to include information about whether providers are accessible via telemedicine.60 Fourteen states have standards with stipulations to attend to the needs of patients with disabilities, including by requiring that directories be available using adaptive technology and/or that the physical accessibility of providers’ offices be indicated in their directory listing.61 Twenty states incorporate provisions to support patients with LEP, such as offering directories in multiple languages and/or requiring providers to indicate spoken language(s) in their directory listing.62

Moreover, several states have taken steps to ensure that QHP enrollees can locate providers who are equipped to care for patients with diverse social identities and cultural backgrounds. Twelve states require that a provider’s gender is included in their directory listing;63 this, among other things, allows women who are pregnant to seek out female providers if they choose. Women may prefer to be seen by providers who are also women for many reasons: Evidence suggests that, in some cases, female providers are linked to better outcomes than male providers for female patients,64 and some women may prefer to be seen by women due to previous experiences with trauma or sexual assault.65 Massachusetts’ Provider Directory Task Force published recommendations in 202066 that suggest including providers’ race and ethnicity in directories on at least an optional basis, as race concordance is associated with improvements in clinical communication67 and patient satisfaction.68 The task force also suggested including specific populations served in directories—such as patients from certain racial/ethnic backgrounds, the LGBTQ+ community, or service veterans—to help patients identify providers who are well positioned to meet their specific needs. Making these recommendations requirements would undoubtedly improve patient-provider relationships—and as a result, improve patients’ engagement with care and clinical outcomes.

Requiring QHPs to produce provider directories that allow patients to connect with providers who can meet their needs is a key component of network adequacy standards that can address and reduce inequities in health care. As such, federal standards for provider directories should lay out concrete quality expectations, both for directory administration—including update frequency and filtering capacity—and for provider information included in directories, such as gender, race/ethnicity, and communities served.


The Biden administration’s new proposed standards are an important step forward in the effort to address the United States’ maternal health crisis. As federal regulators continue to strive to address this crisis, they can use state examples of creative and comprehensive network adequacy guidelines as a road map for strengthening the QHP network standards they set and enforce. While network adequacy is only one piece of what must be a multipronged approach to improving health equity, ensuring that patients and pregnant people can access the right provider, in the right place, at the right time, and in the right way, would go a long way toward ensuring that all people receive high-quality care that meets their needs.