Need an escape from crowded malls, holiday meal planning and travel plans? We’ve got the solution: escape to a quiet corner of your home with steaming cup of hot coco, a warm blanket and hundreds of pages of proposed federal regulations. Tempting, right? Well, in case this activity doesn’t make it to the top of your to-do list this month, we’ve outlined the need-to-know facts and important opportunities for consumer advocates to weigh in on strengthening federal network adequacy requirements.

When consumers enroll in a health insurance plan, they are entitled to an adequate network that has a sufficient number of providers to deliver the health care services included in the plan’s benefit package. Over the past year, due to the existing feedback loops capturing consumers’ experience, advocates across the nation have reported a number of cases where consumers enrolled in new health plans through Marketplaces found that their plan did not meet their care needs as a result of limited network of providers. To ensure consumers have confidence they can access needed care in a timely manner under the plan of their choice, the Centers for Medicare and Medicaid Services (CMS) recently released a proposed regulation to strengthen network adequacy requirements. This is a step in the right direction, but there is more work to be done to ensure that consumers have access to robust networks that meet their care needs. Below are the key highlights on the new network adequacy requirements.

Essential Community Provider (ECP) Requirements: CMS expands the list of ECP’s categories and types to include ECPs that are state-owned, government, and not-for-profit facilities including family planning service sites regardless of whether they receive federal funding under specific federal programs. This expansion would further ensure that Marketplace enrollees from low-income and racially diverse communities residing in low-income zip codes or health professional shortage areas have access to needed care services in a timely manner.

Provider directory requirements: CMS requires that the provider directories must be updated at least once a month and available online to both enrollees and consumers shopping for coverage without requirements to log on or enter a password or a policy number to ensure consumers have an up-to-date, accurate and complete provider directory.

Network adequacy requirements: CMS clarifies that out-of-network providers cannot be counted in determining network adequacy. This would prevent any confusion consumers might face when accessing care. Furthermore, CMS is waiting for the results of the National Association of Insurance Commissioners (NAIC)’ revision of its network adequacy model act before proposing significant changes in these requirements.

This is an opportunity for consumer advocates to weigh in to influence the final rule. A new report on states’ oversight of health plan network adequacy conducted by the NAIC consumer representatives highlights state approaches to regulating and monitoring the adequacy of health plan provider networks. The report also includes a set of recommendations for improved oversight, such as:

(1)    Set clear quantitative standards for network adequacy to ensure consumers have access to needed care in a timely manner. These standards could include: minimum numbers and types of providers in the network, time and distance standards for services, and maximum appointment waiting times.

(2)    Develop stronger language on transparency regarding the type of plans being sold and the accuracy of plan provider directories to ensure that consumers can make the right choice when selecting health plans for themselves and their families. Consumers need reliable, easy-to-use information in order to make optimal choices – information that is not available in the Marketplaces today.

(3)    Create provisions that protect consumers from surprise “balance billing” by out-of-network providers to reduce the burden of unexpected and expensive bills consumers might face at a time when they are most vulnerable.

(4)    Create provisions that ensure continuity of care protections for consumers. Provider networks can change over the course of the plan year for any reason, including because a provider chooses to leave the network. A grace period with a provider who leaves the network before transitioning to another in-network provider would help ensure continuity of care in these situations. This would be particularly helpful for people with chronic conditions.  

This report is a helpful resource as we are working on comments to improve the proposed regulations.

If you have questions or ideas for future materials on network adequacy, please contact Quynh Chi Nguyen, Program & Policy Associate; Staff Lead, Health Equity at qnguyen@communitycatalyst.org.