- The number of health insurance plans with limited networks continues to grow, both in the ACA exchange markets and off, raising issues about how best to regulate them and ensure network sufficiency, a new policy brief from Health Affairs and the Robert Wood Johnson Foundation says.
- Advocates of qualitative standards say flexibility is needed to account for regional differences in population, provider density and market dynamics, while proponents of quantitative metrics see value in transparent standards that can be measured and applied equally in all plans.
- Efforts to get states to adopt a model law aimed at regulating network adequacy have seen little traction.
Narrow networks may offer consumers value, but that is in the “eye of the beholder,” the brief says. While plans with limited networks may have lower premiums, if they are too narrow they may prevent patients from getting the care they need. A study by Harvard researchers of plans on the public exchanges in 2015 found roughly 15% lacked in-network doctors for at least one specialty, according to the brief.
While federal regulations and guidance define network standards under the ACA, it is based on a qualitative standard that calls for a “sufficient” number and type of providers and disclosure of provider directories.
“With these requirements serving as a regulatory floor, the ACA gives states significant latitude to continue to address network issues. States can choose to exercise primary responsibility for insurer oversight and compliance with the federal standard and retain authority to enforce additional state-specific network rules, so long as they do not conflict with federal law,” the authors wrote. “Thus, for example, states that use quantitative measures of network adequacy can apply those standards to qualified health plans just as they do for non-Marketplace plans.”
In 2015, the National Association of Insurance Commissioner approved a revised version of a 1996 model law, endorsing a qualitative standard for assessing network sufficiency. The goal was to get a majority of states to adopt it by 2018. “Should state interest in the model act … remain limited, the likelihood that federal regulators take their own steps to strengthen network requirements for Marketplace plans will increase,” the authors wrote.
They point out, for example, that the government has already implemented quantitative standards for evaluating Medicare Advantage networks and will require numeric measures for Medicaid managed care plans starting in 2018.