Network adequacy – the ability of a health plan to provide enrollees with timely access to needed care included in the benefit contract – continues to capture headlines throughout the country as states consider how to engage in the conversation about provider networks. As consumers begin to access their new health benefits, some are concerned that their networks do not provide them robust access to needed and/or existing providers. Providers and hospitals also continue to express frustration at their exclusion from networks. Similarly, insurers argue that narrow networks—a growing trend prior to the passage of the Affordable Care Act—deliver lower premiums. The answer, perhaps, is somewhere in the middle.

States are getting engaged

In New Hampshire, the Department of Insurance held a public hearing on network adequacy last week where providers, hospitals and patients advocated for renewed scrutiny of Marketplace plans. A number of hospitals were omitted from plan networks or were never offered the opportunity to negotiate plan participation. Frisbie Memorial Hospital, one of 10 hospitals excluded, testified that their exclusion was an attempt to avoid patients with more complex health needs. In response, Insurance Commissioner Roger Sevigny stated that he would convene a working group to review network adequacy standards in the state, stopping short of reversing the approval of plans and their networks. One challenge in New Hampshire is the lack of insurer competition where one carrier, Anthem, drives the Marketplace market.

In Washington state, developing a network adequacy standard is well underway. This past fall, Seattle Children’s Hospital challenged the state when they were left out Marketplace plans, filing suit against the state arguing that children lacked provider access. Children are one sub-population that may face unique needs, requiring access to specialized hospitals. The Department of Insurance (DOI) had previously rejected a number of plans, in one case citing an inadequate network. Currently, the DOI is in the process of developing stronger network adequacy standards; the insurance commissioner is working closely with advocates in crafting a new standard. Early signs are that new guidance will strengthen the standards, inclusive of tougher standards to ensure robust provider networks as well as new transparency requirements.

CMS weighs in too

On February 4, the federal government weighed in through its annual issuer letter that proposes guidelines for 2015 Federally-Facilitated Marketplace plans. Network adequacy is included in this letter as well as sections on Essential Community Providers (ECPs) and discriminatory benefit design. With respect to network adequacy, CMS proposes to collect and review provider lists to ensure access to care without reasonable delay. CMS also proposes that plans include 30 percent of ECPs as opposed to the 20 percent threshold required in 2014. Finally, with respect to discriminatory benefit design, CMS intends to perform outlier analyses across multiple plan attributes such as drug step therapies and cost-sharing. We applaud CMS for their steps toward ensuring consumers can access more robust and inclusive networks. However, there is more work to be done to secure timely access to high quality and affordable care. While the timeline for commenting is short (the due date is February 25), advocates should consider weighing in. To learn more about the issuer letter, see this Health Affairs blog post.

What consumer advocates can do

Consumer advocates can play a helpful and instructive role in the conversations that are underway at community, state and federal levels about network adequacy. For example, it is important to understand your state’s standard as these may differ market to market. Consumer advocates should listen to the needs of consumers in their communities and help educate their coalitions about network adequacy. Finally, consumers can raise these challenges with both regulators at the state and federal level.