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Hot Topic Update: Network Adequacy

network_adequacyWith open enrollment in full swing, Georgia consumers are once again exploring their health insurance options and signing up for coverage. When consumers enroll in a health insurance plan, they gain access to a network of medical providers with whom their insurer has contracted. For health insurance to facilitate meaningful access to care, this network of providers must be adequate to ensure that consumers enrolled in the plan have reasonable access to all covered benefits and services. In a recent issue of the Peach Pulse, we provided a primer on network adequacy, a hot topic in health policy (click here to get caught up on what network adequacy means and why it matters for consumers, advocates, and policymakers). In that overview, we promised to keep you updated on policy developments around network adequacy, in particular the ongoing process at the National Association of Insurance Commissioners (NAIC) to update its model law. This model law can provide a framework for states to establish and enforce standards to ensure that provider networks are adequate. At its fall meeting in November, the subgroup at the NAIC working on network adequacy announced it would take comments on an initial draft of proposed revisions for the model act until January 12, 2015. To learn more about this process and to see the draft, click here.

 

To ensure the needs of consumers are considered in this process, the NAIC consumer representatives released a report featuring the results of a survey of state Departments of Insurance and recommendations for state policymakers, regulators, and the NAIC to consider as they work on updating network adequacy standards. These recommendations include:

 

  • Establish quantitative standards for meaningful, reasonable access to care, such as minimum provider-to-enrollee ratios, reasonable wait times for appointments based on urgency of the condition, and distance standards that require access to network providers within a reasonable distance from the enrollee’s residence.
  • Ensure consumers are provided sufficient information to identify and select between broad, narrow or ultra-narrow networks. In areas without sufficient choice, require health plans to offer at least one plan with a broad network or an out-of-network benefit, with limited exceptions to be determined by the Commissioner.
  • Require health plan provider directories to be updated regularly, publicly available for both enrolled members and individuals shopping for coverage, and include standards for information that must be included to provide consumers with information on network differences and the potential financial impact on consumers depending on which plan they choose.

 

 

There are 17 recommendations in all. For advocates interested in learning more about this issue and in speaking up for consumers in this process, see the full report here.

 

If you would like to weigh in at the state level, please contact Georgia’s Department of Insurance and ask the Commissioner to support the NAIC’s process to revise the model act and specifically to support the consumer recommendations described above.

 

If you are an individual consumer enrolled in a commercial health plan and the provider directory you were given was incorrect or if you have concerns about your ability to access covered services under your plan, please contact the Georgia Office of Insurance & Fire Safety, Consumer Services Division by calling (800) 656-2298 or use the Consumer Complaint Portal at www.oci.ga.gov/ConsumerService. Please also consider sharing your story with Georgians for a Healthy Future so we can get a better picture of what is happening in our state.

 


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