Learn more about our advocacy position on the issue of network adequacy, including what it is, the solutions we endorse and current legislative trends.
- 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.
- 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.
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.
Share Your Story
Have you experienced this in your care journey?Share Today
Advocate for What's Right
As an Arthritis Advocate, you’ll feel good about taking action to make health care more accessible. Help shift the policy and public perception that affects those living with arthritis.