3 lessons on regulating health plan network adequacy

U.S. roadmap
To assess how different states are handling network-adequacy oversight, the Urban Institute examined regulators' efforts in California, Colorado, Illinois and Nevada.

As narrow-network health insurance plans continue to proliferate, state regulators are stepping in to ensure that these benefit designs don’t harm patients' access to healthcare.

As these regulators look to develop better oversight, they can learn from an analysis of four states that have considerable experience analyzing, monitoring and enforcing network adequacy standards, according to a new report from the Urban Institute.

While there are few “one-size-fits-all” solutions to ensure health plan network adequacy, California, Colorado, Illinois and Nevada have gleaned key lessons and best practices that can inform other regulators, the report said. They include:

  • Quantitative standards and other metrics provide a baseline for regulators to assess network adequacy, letting them “compare apples to apples over time” and make insurers more accountable for network design. Indeed, all four states use quantitative standards, though Nevada recently scaled its back. Regulators do, however, need flexibility when applying these standards; for example, they might need to make exceptions in areas with significant provider workforce shortages or geographic barriers.  

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  • Regulators in the four states increasingly used standardized templates and reporting in order to review provider networks, but they also emphasized that it is important to review narrative descriptions of how insurers create their networks, as well as document insurers’ provider access–related policies and procedures. Indeed, as one health plan respondent put it, “You can’t [regulate network adequacy] in a vacuum without appreciating the market dynamics at play.”
  • States vary both in the extent to which regulators require insurers to change or supplement proposed networks, and in their transparency about insurer network submissions and regulators’ review of those submissions. While regulators often engage with insurers about their network adequacy, only some reported lengthy back-and-forth exchanges took place. As for transparency, generally insurer-submitted network filings are only accessible through public records requests, and none of the states publishes any regulator-insurer correspondence on the adequacy of a proposed provider network ahead of selling the plan to the public.

Previously, consumer advocacy organization Families USA touted Georgia, Maryland and Colorado’s successes in the push to improve network adequacy and provider directories. Trade group America’s Health Insurance Plans, however, has pointed out that provider shortages make it increasingly difficult for insurers to comply with network adequacy standards.