Arthritis Foundation Legislative Position Statements

Arthritis Foundation Position Statement on Narrow Provider Networks/Network Adequacy Issue

Issue

Many people with arthritis who are enrolling in health insurance plans are learning that the availability of doctors, specialists and hospitals through those plans is extremely limited. Patients who do not have access to necessary medical care through their insurance plans are forced to use “out-of-network” providers for care. Because insurers do not pay for out-of-network care, patients only have access to care that is specific to their needs by absorbing a substantial cost sharing obligation or by switching doctors.

Background

Many health insurance plans limit the number of doctors, hospitals, facilities and services that are available to their plan enrollees. Those providers that are in the plan’s network are generally covered and the use of a provider that is not within the plan is considered out-of-network and is not covered by the plan. Patients who use out-of-network providers typically pay significantly more than they would for providers in a plan – or even all of the cost without any contribution from their insurer.

A plan with few choices is considered to have a “narrow network.” Some narrow networks have been identified without the availability of a nearby hospital, absence of specialists, facilities in geographically unfavorable distances from population centers and physicians who are overbooked or not taking on new patients. The inadequacy of a narrow network to serve the diverse needs of its enrollee population can serve as a direct impediment for access to care.

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