Network Adequacy 

Learn more about our advocacy position on the issue of network adequacy, including what it is, the solutions we endorse and current legislative trends. 

The Issue

  • Many health insurance plans, through a narrow network, limit the number of doctors, hospitals, facilities and services that are available to their plan enrollees.
  • People who do not have access to necessary medical care through their plan network are forced to use significantly more expensive "out-of-network" providers for treatment.
  • Because insurance providers often do not pay for out-of-network care, patients only have access to care that is specific to their needs by absorbing substantial cost-sharing obligations or by switching doctors. Consequently, insufficient networks can impede access to care.

The Solution

  • Insurance plans must ensure an adequate network based on clinical appropriateness, the nature of the specialty and the urgency of care.
  • Insurance plans must ensure a sufficient number of geographically accessible health care providers, including specialists, for the number of enrollees in a given region.
  • At a minimum, network adequacy standards should include a time and distance standard, in addition to wait times and whether providers are taking new patients.
  • An insurance plan that is unable to provide sufficient access to required providers must ensure that an enrollee may obtain a covered benefit at no greater cost to the person than if the benefit were obtained from participating providers.

Current Trends

In 2012, the National Association of Insurance Commissioners released a white paper outlining minimum network adequacy standards and model legislation.  This model bill was updated in 2015 to address surprise out-of-network charges by consumers in a piece of model legislation called the Health Benefit Plan Network Access and Adequacy Model Act. 

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