Dive Brief:
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Many insurance policies offered via the public marketplace have limited networks of providers, and as reported by The New York Times, these "narrow networks" do not include physicians needed for specialized care. In response, the National Association of Insurance Commissioners is recommending insurers have sufficient physicians and hospitals in their networks to provide services "without unreasonable travel or delay."
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The goal is to prevent huge bills should the consumer receive care outside their insurance network. The commissioners' proposal would require, via a model state law, insurers and hospitals inform patients of any possibility they may be charged extra by a healthcare professional (pathologist, radiologist, etc) outside the insurer's network.
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State insurance commissioners will need to consider factors including: The ratio of enrollees in a health plan and the number of physicians in each speciality, the geographical accessibility of providers, wait times for appointments, and the ability of health plans to meet the needs of low-income individuals and those with serious, chronic or complex health issues or physical or mental disabilities, to determine if a provider network is sufficient. Another provision will require insurers to update their physician directories at least once a month.
Dive Insight:
The proposals were developed by the commissioners over an 18-month drafting process open to consumers, insurers, healthcare providers, and other experts. The Obama administration said it was waiting to see the "model act" before deciding whether to adopt federal standards for provider networks.
However, insurers, reports the The New York Times, opt for smaller networks to keep costs affordable and improve care by sending patients to selected high-performing physicians and hospitals. Recent studies by the Robert Wood Johnson Foundation and Avalere Health showed insurers in the federal marketplace are offering fewer plans than they did in the past two years and many insurers are reducing or cutting coverage for out-of-network providers.
In another recent study, Harvard researchers said almost 15% of health plans in the federal marketplace exchange "completely lacked in-network physicians for at least one speciality" - mostly rheumatologists, endocrinologists, and psychiatrists.