Health Insurance and Network Adequacy Postcard

7/30/2015

Health insurers typically determine the providers and facilities that their consumers may use to obtain health services under a particular plan, which helps insurers manage services and control costs. State “network adequacy” laws are designed to ensure that health insurance consumers have “adequate” access to providers and care to meet their needs, and first gained traction in the 1990s. The Affordable Care Act (ACA) created the first federal standards for health care plans offered through insurance marketplaces.

As of 2015, 39 states and the District of Columbia have implemented qualitative and/or quantitative standards for network adequacy in health insurance plans.

Qualitative measures include requirements such as ensuring a sufficient number of providers in a given geographic area, reasonableness of patient access to providers, and network adequacy generally.

Quantitative measures include specific, measureable requirements for health insurance plan networks, such as specifying a maximum distance a patient has to travel to reach a provider, numbers of in-network providers, and the hours and availability of in-network providers.

United States map of Health Insurance and Network Adequacy postcard

Resources:

NCSL's Health program maintains a Health Innovations Database, with support from The Commonwealth Fund, where users can search for the latest network adequacy legislation

See NCSL’s network adequacy page

Related Commonwealth Fund Brief