State insurance regulators take on narrow-network debate

State regulation of network adequacy is anything but stable. While some states have guidelines in place to assure consumers see certain providers, others may have specific quantitative measurements.

In an effort to better regulate narrow networks, the National Association of Insurance Commissioners (NAIC) is working to hash out a new model network adequacy law, reports Managed Care magazine.

When the Affordable Care Act was first implemented, it mandated that health plans sold on the insurance exchanges remain "sufficient in numbers and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay," notes the article.  

But now, network adequacy is a hot-button issue. For instance, four states have the highest percentage of narrow-network plans: Georgia, Florida, Oklahoma and California. In these states, at least 75 percent of marketplace plans have narrow networks that cover 25 percent or fewer of all area physicians, according to a recent study from the University of Pennsylvania's Leonard Davis Institute.

To address the growing concerns regarding narrow networks--as well as the relationship between insurers and providers--the NAIC's new standards will focus on a variety of aspects, including: Network adequacy, access to plans, tiering, balanced billing, continuity of care and provider directories, according to the magazine.

The working document says network adequacy would be determined using "reasonable criteria," such as provider-covered person ratios by specialty, geographic accessibility of providers and wait times.

What's more, the NAIC wants to improve rules that would strengthen transparency for consumers and update provider directories. The federal government has similar goals: Earlier this year, the Centers for Medicare & Medicaid Services announced that health insurers must provide up-to-date doctor lists for their Medicare Advantage and Healthcare.gov policies starting next year.

For more:
- here's the article

Free Webinar

Take Control of Your Escalating Claim Costs through a Comprehensive Pre-payment Hospital Bill Review Solution

Today managing high dollar claim spend is more important than ever for Health Plans, TPAs, Employers, and Reinsurers, and can pose significant financial risks. How can these costs be managed without being a constant financial drain on your company resources? Our combination of the right people and the right technology provides an approach that ensures claims are paid right, the first time. Register Now!

Suggested Articles

CMS is proposed to lower the user fee for ACA exchange insurers and wants to enable the private sector to develop competing signup websites.

With the distribution of a COVID-19 vaccine looming, companies in the pharmaceutical supply chain are working overtime to plan for all contingencies.

The pandemic is transforming the way the healthcare industry handles payments. Here are key takeaways on the benefits of automated payments.