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Insurance Carriers and Access to Healthcare Providers Network Adequacy

Insurance Carriers and Access to Healthcare Providers | Network Adequacy

Ashley Noble 6/27/2014

Health insurance carriers generally have the ability to define and adjust the number, the qualifications and the quality of providers in their networks. They also may limit the number of providers in their networks as a means of conserving costs. In so doing, carriers may narrow their provider networks to an extent that enrollees in insurance plans may have relatively or extremely limited options when choosing providers.

Network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract.  States have addressed this issue by enacting laws to ensure that provider networks are of “adequate” size.

State policymakers face questions caused by the ongoing need to balance the interests of insurers who may want to achieve limits on costs and exclude low performers, the interests of providers, such as physicians, clinics, and hospitals, who seek the right or choice to treat patients needing their services, and the interests of patients, who often prefer, or medically need, a choice of providers, or the ability to use a particular provider.

The Affordable Care Act

The establishment of Health Benefit Exchanges, also termed Health Marketplaces, by the Affordable Care Act of 2010 (ACA) has renewed the examination and policies set by state and federal law. The ACA requires that all “Qualified Health Plans” include an “adequate network of primary care providers, specialists, and other ancillary health care providers.”

The ACA requires the Secretary of the Department of Health and Human Services (HHS) to establish criteria for the certification of health plans as Qualified Health Plans (QHPs) to be offered on a state’s Health Insurance Exchange.* These criteria include requirements to:

  • Ensure a sufficient choice of providers;
  • Include essential community providers in accordance with 45 CFR § 156.235;

State Laws Related to Access to Healthcare Providers Network Adequacy

Several recent state statutes specific to exchanges set standards or definitions related to network adequacy – see examples in California, Connecticut, Hawaii, Washington and the District of Columbia. A list of network adequacy statutes in 21 states and D.C. follows in the chart below. At least 10 states had enacted and operational laws prior to the 2010 ACA. 

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State

Summary

Years with Legislative Action

California

 

Cal. Welf. & Inst. Code § 14132.275.

The Department of Health Services shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program and the federal Medicare Program. Includes provisions to ensure network adequacy.

2010, 2011, 2012, 2013, 2014

Cal. Welf. & Inst. Code
§ 14182.16 and § 14182.17.

Requires the department to monitor the provider networks of managed health plans to ensure network adequacy.

Requires the department to ensure managed health plans compliance with network adequacy requirements, including geographic accessibility of providers, long-term services requirements, the development and maintenance of lists of providers currently accepting new patients and monitoring of networks to ensure an adequate number of providers in a given area.

2012, 2013, 2013

Colorado

 

Colo. Rev. Stat. Ann. § 10-16-704.
CO regulation: (25.5-5-403;
3 CCR 702-4

“A carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay.”

1997, 2001, 2002, 2003, 2006, 2010, 2013

Connecticut

 

Conn. Gen. Stat. Ann. § 38a-472f

Requires carriers to ensure that their networks have adequate numbers of providers. Requires consistency with the standards set by the National Committee for Quality Assurance “or URAC's provider network access and availability standards.”

2011

Conn. Gen. Stat. Ann. § 38a-1085

Allows the inclusion of limited network dental plans to be included in the Exchange if those plans provide for pediatric dentistry.

2011

Conn. Gen. Stat. Ann. § 38a-1086

Establishes the standards required for plans to be included on the Exchange, established in 2011 by C.G.S.A. § 38a-1081. Requires carriers to “charge the same premium rate for each qualified health plan without regard to whether the plan is offered through the exchange or directly by the health carrier or through an insurance producer.”

2011

Florida

 

Fla. Stat. Ann. §409.967

Requires the agency to enter into a five-year contract with a managed health plan. The plan must have an adequate regional network of providers.

2011, 2012

Florida

 

Fla. Stat. Ann. §409.975

Allows managed care networks which are part of the managed medical assistance program to “limit the providers in their networks based on credentials, quality indicators, and price.”

2011, 2012

Florida

 

Fla. Stat. Ann. §409.91211

Establishes a pilot program that will be limited to Broward County. Requires the agency to ensure that capitated managed care programs provide adequate access to providers.

2005, 2007, 2009, 2010, 2011

Hawaii

 

Hawaii Rev. Stat. § 432F-2.

Requires managed care plans to demonstrate the adequacy of their provider networks to the commissioner no later than Jan. 1 of each year.

2013

Hawaii

 

Hawaii Rev. Stat. § 435H-11

“The commissioner shall provide the Hawaii health connector, established in 2011 by HRS § 435H-2 with a list of qualified health plans that meet network adequacy standards as determined by the commissioner.”

2013

Illinois

 

Ill. Stat. Ann. ch. 325 §20/13.20

Allows managed care plans to specify that children be treated by providers within the plan’s network, so long as certain conditions are met, including:

  • “the network provider is immediately available to receive the referral and to begin providing services to the child;”
  • “the network provider is enrolled as a provider in the Illinois early intervention system and fully credentialed under the current policy or rule of the lead agency;”
  • “the network provider can provide the services to the child in the manner required in the individualized service plan;”
  • “the family would not have to travel more than an additional 15 miles or an additional 30 minutes to the network provider than it would have to travel to a non-network provider who is available to provide the same service; and”
  • “the family's managed care plan does not allow for billing (even at a reduced rate or reduced percentage of the claim) for early intervention services provided by non-network providers.”

2001

Louisiana

 

La. Rev. Stat. Ann. tit. 22 §1019.2

“A health insurance issuer providing a health benefit plan shall maintain a network that is sufficient in numbers and types of health care providers to ensure that all health care services to covered persons will be accessible without unreasonable delay.”

2013

Maryland

 

Md. Insurance Code §31-115

Allows the state Exchange to deny certification to health plans that do not meet standards for network adequacy and plan service area.

2011, 2012, 2013

Massachusetts

 

Mass. Gen. Laws Ann. ch. 176J §11

Requires certain carriers to offer at least one benefit plan in at least one geographic area that provides at least one of the following:

  • a reduced or selective network of providers;
  • a smart tiering plan in which health services are tiered and member cost sharing is based on the tier placement of the services; or,
  • a plan in which providers are tiered and member cost sharing is based on the tier placement of the provider.

2010, 2011, 2012

Michigan

 

Mich. Comp. Laws Ann. §500.3428

“Beginning Jan. 1, 2014, an insurer shall establish and maintain a provider network that, at a minimum, satisfies any network adequacy requirements imposed by the commissioner pursuant to federal law.”

2013

Michigan

 

Mich. Comp. Laws Ann. §550.1501c

“Beginning Jan. 1, 2014, a health care corporation shall establish and maintain a provider network that, at a minimum, satisfies any network adequacy requirements imposed by the commissioner pursuant to federal law.”

2013

Minnesota

 

Minn. Stat. Ann. §62D.124 and

Minn. Stat. Ann. §62K.10

“Within the health maintenance organization's service area, the maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the nearest provider of each of the following services: primary care services, mental health services, and general hospital services.”

 

“Within a health maintenance organization's service area, the maximum travel distance or time shall be the lesser of 60 miles or 60 minutes to the nearest provider of specialty physician services, ancillary services, specialized hospital services and…other health services.”

 

Establishes the maximum travel time to the nearest “primary care services, mental health services, and general hospital services” be limited to 30 miles or 30 minutes. Requires the travel time to the nearest  “provider of specialty physician services, ancillary services, specialized hospital services, and…other health services”  be limited to 60 miles or 60 minutes. Requires that networks contain a sufficient number and type of providers.

1999, 2012, 2013

Minnesota

 

Minn. Stat. Ann. §62K.14

Requires limited scope pediatric dental plans to be offered to the extent permitted under the ACA. Establishes limits and requirements for discontinuing a limited scope pediatric plan. Requires that providers in a limited scope pediatric plan be accessible within 60 miles or 60 minutes travel time. These provisions apply only to plans renewed after Jan. 1, 2015.

2013

Montana

 

Mont. Code Ann. §§33-36-101—402

“A health carrier offering a managed care plan in this state shall maintain a network that is sufficient in numbers and types of providers to ensure that all services to covered persons are accessible without unreasonable delay.”

1997

Nebraska

 

Neb. Rev. Stat. §§ 44-7101—7112

“A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all health care services to covered persons will be accessible without unreasonable delay.”

1998

New Hampshire

 

N.H. Rev. Stat. § 420-J:7

“ A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.”

2008

New Hampshire

 

N.H. Rev. Stat. §420-N:8

“In the event a federally-facilitated exchange is established for New Hampshire, the commissioner shall retain authority with respect to insurance products sold in New Hampshire on the federally-facilitated exchange to the maximum extent possible by law as provided in title XXXVII, including but not limited to…network adequacy…”

2012

New York

 

N.Y. Public Health Law § 4403-f.

Requires carriers to demonstrate to the commissioner that “the contractual arrangements for providers of health and long term care services in the benefit package are sufficient to ensure the availability and accessibility of such services to the proposed enrolled population consistent with guidelines established by the commissioner” in order to receive certification.

1997, 2004, 2005, 2006, 2007, 2008, 2010, 2011, 2012, 2013

Oregon

 

Ore. Laws 2012, Ch. 80, § 4.

Forbids coordinated care organizations from discriminating against health providers who are acting within their scope of practice. In determining whether discrimination has occurred, the authority must consider an organization’s network adequacy.

2012

South Dakota

 

S.D. Codified Laws §§58-17F-2—21

Requires managed care networks to maintain networks of providers of sufficient adequacy to ensure reasonable access.

2011

Tennessee

 

Tenn. Code Ann. § 56-7-2356

“Each managed health insurance issuer that offers a plan that limits its enrollees' choice of providers shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay.”

1998, 1999, 2008

Texas

 

Tex. Insurance Code Ann. § 1301.0055

Requires the commissioner to adopt network adequacy standards that ensure access to “a full range” of physician providers.

2009

Vermont

 

Vt. Stat. Ann. tit. 33 §1806

“A qualified health benefit plan shall meet the following minimum prevention, quality, and wellness requirements, [including]…network adequacy…”

2011

Washington

 

Wash.  Rev. Code Ann. §43.71.020 and
Wash.  Rev. Code Ann. §43.71.070

Washington established the Washington Health Benefit Exchange in 2012.  The law provides that:

“The board shall establish a rating system consistent with section 1311 of P.L. 111-148 of 2010, as amended, for qualified health plans to assist consumers in evaluating plan choices in the exchange. Rating factors established by the board may include, but are not limited to…network adequacy.”

2011, 2012

District of Columbia

 

D.C.  Code Ann. §31-3171.02 and

D.C. Code Ann. §31-3171.09

The District of Columbia established the Health Benefit Exchange Authority in 2012.  It requires carriers to meet standards for network adequacy to be certified.

2012

Additional Resources

Authors: This material was researched and compiled by Ashley Noble, Research Analyst with the Health Program in Denver.

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