Health Insurers and Access to Health Care Providers: Any Willing Providers
“Any Willing Provider” statutes, sometimes referred to as “Any Authorized Provider,” are laws that require health insurance carriers to allow health care providers to become members of the carriers’ networks of providers if certain conditions are met. Such statutes prohibit insurance carriers from limiting membership within their provider networks based upon geography or other characteristics, so long as a provider is willing and able to meet the conditions of network membership set by the carrier.
Laws can be broad in scope, applying to all or most licensed providers in the state. Broad laws typically either spell out a list of providers covered by the provisions (e.g., physicians, pharmacists, chiropractors, speech therapists, podiatrists, optometrists, facilities, etc.) or assert that the provisions apply to all providers licensed in the state without specifically listing any.
Laws can also be limited in scope. Frequently, the limited provisions apply to only pharmacies or pharmacists. In some cases, they apply to a limited number of allied professionals such as chiropractors, optometrists, psychologists and social workers.
The Employee Retirement Income Security Act (ERISA) and Federal Preemption
As with most state regulation of insurance, “Any Willing Provider” laws generally apply to only state regulated policies, especially "fully funded" insurance, and do not apply to "self-funded" insurance plans, such as those offered by the largest employers. ERISA creates rules and standards for employers who choose to offer pensions and health benefits to employees. ERISA prevents states from imposing conditions on such "ERISA-protected" health insurance plans. This is known as federal preemption of state laws.
Examples of Any Willing Provider statutes that have been preempted by ERISA include:
- Louisiana: LSA-R.S. 40:2202 and
- Texas: V.T.C.A., Insurance Code Art. 21.52B.
See ERISA Appendix for an explanation of the court decisions
State Statutes
Twenty-seven states currently have “Any Willing Provider” statutes, including Alabama, Arkansas, Connecticut, Delaware, Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Massachusetts, Minnesota, Mississippi, Missouri, New Hampshire, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin and Wyoming. Many of these laws have been in force for decades; however, the most recent enacted law changes were passed in 2013. On Nov. 7, 2014 South Dakota voters approved a broad any willing provider binding ballot question.
The requirements of these laws are summarized in the chart below.
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Citation
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Application/Summary
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Years of Legislative Actions
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Alabama
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Ala. Code 1975 § 22-6-158
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Applies to hospitals, doctors, and any other provider to provide Medicaid services.
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2013
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Ala. Code 1975 § 27-45-3
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Applies to pharmacists and pharmacies.
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1988
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Arkansas
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Ark. Code Ann. §§23-99-201—209
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Allows enrollees to select their health care provider. Allows patients to sue insurers or managed-care company for violations. They are "intended to prevent managed care medical benefit plans from excluding medical providers as long as the provider is willing to accept the plan's rates as payment for services."
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1995 (law upheld in 2005)
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Ark. Code Ann. §§23-99-801—803
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Applies to a broad range of providers.
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2005, 2009
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Connecticut
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Conn. Gen. Stat. Ann. §38a-471
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Applies to pharmacies.
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1958, 1981, 1982
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Delaware
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18 Del. Code §7303
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Applies to pharmacies.
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1994, 1995
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Georgia
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Ga. Code Ann., § 33-20-16
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Applies to “Every doctor of medicine, every doctor of dental surgery, every podiatrist, and every health care provider within a class approved by the health care corporation.”
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1976
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Idaho
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Idaho Code Ann. § 41-3927
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Applies to all health care providers.
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1994, 1997, 1998
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Illinois
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215 ILCS 5/370h
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Applies to non-institutional providers.
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1937, 1985, 1998
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215 ILCS 134/72
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Applies to pharmacies.
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2000
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Indiana
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IC 27-8-11-3
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Applies to all providers.
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1984, 1994, 1996, 1998, 1999
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Kentucky
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KRS § 304.17A-270
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Applies to all providers within the geographic area covered by the benefit plan.
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1998
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KRS § 304.17A-171
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Applies to chiropractors.
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1996
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KRS § 304.17C-020
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Applies to all providers within the geographic area covered by the limited health benefit plan.
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2002
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KRS § 304.17A-505
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Requires carriers to inform enrollees that providers have a right to become members of the carriers’ networks if certain conditions are met.
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1998, 2000, 2010
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Louisiana
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LSA-R.S. 22:2181
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Applies to all providers who wish to contract with the Louisiana State University Health Sciences Center Health Maintenance Organization.
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1997, 1999, 2008, 2012
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Maine
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24-A M.R.S.A. § 4317
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Applies to pharmacy providers.
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2009, 2011, 2012, 2013
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Massachusetts
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M.G.L.A. 176D § 3B
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Applies to pharmacies
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1994
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Minnesota
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M.S.A. § 62Q.14
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Allows patients complete freedom of choice of providers for fertility services, family planning services not including abortion, and testing for STIs and HIV/AIDS
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1994
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Mississippi
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Miss. Code Ann. § 83-9-6
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Applies to pharmacists and pharmacies.
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1997
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Miss. Code Ann. § 83-43-13
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Applies to dentists
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1962
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Miss. Code Ann. § 43-11-41
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Allows residents in long term care facilities to choose any pharmacist that meets the standards of the long term care facility.
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2007
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Missouri
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V.A.M.S. 376.325
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Applies to physicians.
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2013
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V.A.M.S. 198.530
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Allows residents in long-term care facilities to receive care in their homes.
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1999
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New Hampshire
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N.H. Rev. Stat. §420-B:12
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Applies to pharmacies
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2008
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New Jersey
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N.J.S.A. 17:48-6j
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Applies to pharmacies
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1993, 1999
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North Carolina
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N.C.G.S.A. § 58-51-37
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Applies to pharmacies
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1993
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North Dakota
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NDCC, 26.1-36-12.2
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Applies to pharmacies and pharmacists.
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1989
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| South Carolina |
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| Code 1976 § 38-71-147 |
Applies to pharmacies and pharmacists. |
1994, 1997 |
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South Dakota
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SDCL § 58-18-37
SD Initiated Measure 17
(2014 ballot initiative, passed, Yes votes: 61.8%)
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Applies to pharmacies and pharmacists.
Applies to "all health care providers who are willing, qualified and meet the conditions for participation"
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1990
2014
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Tennessee
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T. C. A. § 56-7-2359
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Applies to pharmacies and pharmacists.
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1998, 2001
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Texas
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V.T.C.A., Insurance Code § 1579.108
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Applies to general hospitals within a limited region.
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2007, 2009, 2011
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Utah
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U.C.A. 1953 § 31A-22-617
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Any health care provider licensed to treat any illness or injury within the scope of the health care provider's practice, who is willing and able to meet the terms and conditions established by the insurer for designation as a preferred health care provider, shall be able to apply for and receive the designation as a preferred health care provider
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1985, 1993, 1994, 2000, 2001, 2002, 2003, 2005, 2007, 2008, 2009, 2013
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Virginia
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VA Code Ann. § 38.2-3407
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Applies to a broad range of providers
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1986, 2008
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VA Code Ann. § 38.2-3407.7
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Applies to pharmacies
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1994, 1995, 2010
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VA Code Ann. § 38.2-4209
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Applies to a broad range of providers.
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1986, 1999
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West Virginia
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W. Va. Code, § 33-25G-4
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Applies to any physician or behavioral health provider.
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2012
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Wisconsin
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W.S.A. 628.36
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Applies to health care professionals, services, facilities, and organizations.
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1975, 1983, 1985, 1987, 1989, 1991, 1997
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Wyoming
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W.S.1977 § 26-34-134
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Applies to all WY providers.
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1995
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W.S.1977 § 26-22-503
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Applies to all WY providers.
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1985, 1990, 1993, 1995
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Other Related Statutes
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New Mexico
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N. M. S. A. 1978, § 59A-32-22
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Doctors of traditional Asian medicine are licensed providers and should not be discriminated against relative to other providers regarding reimbursement levels and services provided within their scope of practice. This statute pertains to motor vehicle insurance.
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1997
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Ohio
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R.C. § 5126.046
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Allows people with intellectual disabilities to choose any willing provider for residential services.
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2001, 2009, 2012
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Virginia
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VA Code Ann. § 38.2-3407.10
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Carriers shall provide a provider application and the relevant terms and conditions to a provider upon request
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1996, 1999, 2000, 2001, 2004, 2006
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No Longer Operational
- Florida: Fla. Stat. §408.706—repealed in 2000
- Louisiana: LSA-R.S. 40:2202—preempted under ERISA
- Minnesota: M.S.A. § 62Q.14—repealed in 2012
- Texas: V.T.C.A., Insurance Code Art. 21.52B—preempted under ERISA
Other Resources on Insurance Reform
Michael Clark and Ginny Wilson, Market Responses to Kentucky’s Health Insurance Reforms, available at http://cber.uky.edu/Downloads/health99.htm .
2013-2014 Filed and Pending Legislation
As of Jan. 31, 2014, bills have been proposed in four states (Massachusetts, Mississippi, New Hampshire and Pennsylvania) between 2013 and 2014 that propose to implement some version of an “any willing provider” statute. Summaries of these bills follow below.
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Bill Number
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Summary
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Date Filed
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Massachusetts
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MA H 3425
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Mental Health or Substance Abuse Provider Services. Relates to extending health insurance coverage for services rendered by certain licensed mental health or substance abuse providers.
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04/17/2013;
did not pass.
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Mississippi
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MS H 553
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Patient Protection Act. Would create the Mississippi patient protection act of 2014; would provide that a health insurer shall not discriminate against any provider who is located within the geographic coverage area of a health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer; would prohibit a health insurer from imposing a monetary advantage or penalty that would affect a beneficiary's choice.
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01/22/2014;
did not pass.
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MS S 2709
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Patient Protection Act of 2014. Would provide that a health insurer shall not discriminate against any provider who is located within the geographic coverage area of a health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer; would prohibit a health insurer from imposing a monetary advantage or penalty that would affect a beneficiary's choice.
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01/22/2014;
did not pass.
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MS S 2836
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Mississippi Patient Protection Act. Would create the Mississippi patient protection act of 2014; would provide that a health insurer shall not discriminate against any provider who is located within the geographic coverage area of a health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer.
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01/22/2014
did not pass.
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New Hampshire
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NH H 1294
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Health Exchange Participation. Would require "any willing provider" amendment that all providers be allowed to participate in the health exchange.
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01/08/2014;
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Pennsylvania
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PA H 222
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Health Care Benefit Discrimination. Would amend Title 40 (Insurance) of the Pennsylvania Consolidated Statutes, providing for nondiscrimination by payers in health care benefit plans.
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01/22/2013
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PA H 708
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Volunteer Ambulance Services. Would amend the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921; would prohibit discrimination against volunteer ambulance services.
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02/14/2013
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PA H 1622
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Physician Practices in an Integrated Delivery Network. Would require insurance carriers and providers to enter into mutually agreeable contracts. Would require the parties to submit to arbitration in the event a suitable contract cannot be formed.
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10/15/2013
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2014 Ballot Question
South Dakota
Initiated Measure 17: Require Health Insurers to Include All Willing and Qualified Health Care Providers on their Provider Lists
Summary: The initiated measure establishes who is entitled to be on the insurer's list of providers. The measure requires that all insurers list all health care providers who are willing, qualified and meet the conditions for participation established by the insurer. Required a yes or no vote statewide in November 2014; passed by a 61.8% yes vote. [SD Secretary of State explanation] [SD Sec. of State Pro & Con publication]
APPENDIX: ERISA Court Rulings
- Texas: In Texas Pharmacy Ass'n v. Prudential Ins. Co. of America (1997), the court held that V.T.C.A., Insurance Code Art. 21.52B was preempted under ERISA
“because it [was] not limited to entities within the insurance industry. Instead, it also [applied] to health maintenance organizations (HMOs), preferred provider organizations (PPOs), and other organizations that provide health care services. Indeed, since the statute [defined] managed care providers to include HMOs, PPOs or “another organization” that provides health care benefits, it [applied] to ERISA benefit plans themselves.”
- Louisiana: The court in Murphy v. Community Health Network of Louisiana, Inc. (1998) followed the decision in Texas Pharmacy Ass’n. stating that,
“because [LSA-R.S. 40:2202] [denied] insurers, employers, and HMOs the right to structure their benefits in a particular manner, the statute… effectively [required] ERISA plans to purchase benefits of a particular structure when they [contracted] with organizations like CIGNA and Connecticut General Life Insurance Company (CGLIC) and, in this case, CHN. Travelers, 514 U.S. at 658, 115 S.Ct. at 1678. Therefore, because the statutes [mandated] a certain structure which affects employee benefit plans, they [were], accordingly, preempted.”
For more information on ERISA, please click on the following links:
Research and Authors: This report is an expansion and update of state actions taken over the past 25 years. It includes research compiled by Richard Cauchi (covering actions and status from 2000-2012). This substantially expanded report, including current-session legislation, was researched in 2014 by Ashley Noble, JD for the NCSL Health Program, Denver.