Next in Health Care: Network Adequacy Explained

 When consumers enroll in a health insurance plan, they gain access to a network of medical providers. Insurance companies contract with a range of providers, including both primary care and specialty physicians, to deliver health care services included within the plan’s benefit package. This network of providers must be adequate to ensure that consumers enrolled in the plan have reasonable access to all covered benefits. This is what is meant by network adequacy.  More specifically, to be considered adequate, a network must provide adequate numbers, types, and geographic distribution of providers; must ensure that access to care is timely; and must include essential community providers that serve predominantly low-income, medically underserved individuals. Additionally, accurate information about providers must be made available to consumers.

Network adequacy has become a hot topic over the past several months because many consumers who enrolled in new health plans through the Health Insurance Marketplace found that their plan came with a narrow network of providers. Provider directories weren’t always accurate or up-to-date, and consumers expressed a fair amount of confusion over which providers were in their plan’s network.

At the same time, the National Association of Insurance Commissioners (NAIC), which develops model laws and rules that states often adopt, has been working to update its network adequacy model law. Stakeholders ranging from insurers to medical providers to patient and consumer advocates are weighing in on this process, making network adequacy a hot topic in the policy arena too. Georgians for a Healthy Future has been monitoring this process through the participation of our executive director as one of the consumer representatives to the NAIC. Earlier this summer, the consumer representatives submitted comments to the NAIC focusing on developing a stronger standard and better oversight of network adequacy, an end to “balance billing” by out-of-network providers in in-network facilities, and greater transparency of provider networks.

Georgians for a Healthy Future will continue to monitor this process and will advocate at all levels, in conjunction with state and national partners, to ensure consumers have meaningful access to care.

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.

For more information on network adequacy, please see the following reports and resources:

From Georgetown Center on Health Insurance Reforms: Reforming State Regulation of Provider Networks: Efforts at the NAIC to Re-Draft a Model State Law

From Robert Wood Johnson Foundation and Georgetown University Health Policy Institute: ACA Implications for State Network Adequacy Standards

From Families USA: Network Adequacy and Health Equity: Improving Private Health Insurance Networks for Communities of Color

Connecting Georgians to Coverage

The ACA and people living with HIV/AIDS: what you need to know

The Affordable Care Act (ACA) makes health insurance more affordable, more accessible, more understandable, and more complete for all Georgians. Health care and health insurance are especially important to people living with HIV/AIDS (PLWHA) so that they can stay healthy and well.  PLWHA often have very specific needs and questions regarding their health coverage and care options.  To answer them, Georgians for a Healthy Future and Georgia Equality have created a fact sheet that breaks down the biggest concerns and decisions for PLWHA.  The fact sheet details new rights and protections under the ACA, walks through important questions to ask prior to choosing a health plan, and provides contacts for further assistance.

This fact sheet was made to be shared! You can view and download this new fact sheet on the GHF website. If you would like hard copies to distribute to your members, clients, or community partners, please contact Laura Colbert, GHF’s Community Outreach Manager at lcobert@healthyfuturega.org.

Georgia Gives Day

Georgians for a Healthy Future works hard every day to bring about our vision of a day when all Georgians have access to the health care services they need to lead productive lives and contribute to the health of their communities. Whether we’re enrolling people in health insurance, advocating on behalf of health care consumers at the state capitol, working to address substance use among young adults, or convening a coalition to expand Medicaid, we are focused on you and your health.

November 14^th is Georgia Gives Day.  This is a day for Georgians across the state to express their support for the non-profit organizations that enrich our lives.  We hope that you will put November 14^th on your calendar and take a few minutes out of your day to support Georgians for a Healthy Future by making a small contribution.  Look for alerts leading up to the day and please follow us on Facebook and Twitter as we celebrate and work toward our vision of a healthy Georgia.

Stories that Cause Change: How you can make a difference!

The public discussion around the Affordable Care Act is often about its politics. What the pundits miss is that each person’s experiences-whether it is the elation, relief, and sense of security that come with enrolling in health insurance for the first time or the frustration that comes from finding out you fall into the coverage gap–is important.  Whatever your story, we want you to share it with us!

Volunteer!  Throughout open enrollment we will be talking to consumers throughout the state.  You can help us in this important effort by attending an event in your neighborhood and talking to consumers.  We will prepare you with supplies and materials, a how-to guide, and more.  If you would like to help out, please email our outreach manager, Laura Colbert.

Share your story and encourage others to do the same. If you or someone you know has successfully enrolled in a health insurance plan through the marketplace, tell us about it.  If you fall in the coverage gap, let us know.  If you are able to access care that you couldn’t afford before, we want to hear about it.  Tell us your story by contacting our communications coordinator, Anna Cullen.

Together we can make a change.

Medicaid Minute: Uncompensated Care Cost

Last week, HHS released a report highlighting one way Georgia can help our hospitals and reduce uncompensated care costs: closing the coverage gap by expanding Medicaid.  In states that have expanded, uninsured/self-pay admissions as well as uninsured/self-pay emergency visits have fallen.  Those same states have seen hospital admissions for patients with Medicaid increase.  In short, they have more paying customers.  And Georgia is getting left out.  The report shows a $5.7 billion savings to hospitals in uncompensated care because of the Affordable Care Act.  $4.2 billion (74%) of those savings will be to states that have expanded.  Just one more reason why closing the coverage gap is the best option for Georgia’s economy and Georgia’s people!