Many people with arthritis are learning that the availability of doctors, specialists and hospitals through their health plans is extremely limited. People who do not have access to necessary medical care through their plan network are forced to use "out-of-network" providers for treatment. Because insurers 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.
Many health insurance plans limit the number of doctors, hospitals, facilities and services that are available to their plan enrollees. The use of a provider that is not within the plan is considered out-of-network and is typically covered at a less favorable rate or is not covered at all. 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 new patients. Consequently, insufficient networks can impede access to care.
The Arthritis Foundation supports legislation or regulation that limits narrow or inadequate provider networks and should incorporate the following policies:
- Insurance plans must ensure access to care in a way that does not negatively impact an enrollee's health. Insurance plans must ensure a minimum level of care 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.
- 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.
- 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.
- Insurance plans must ensure a sufficient range of services.
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