Network adequacy standards vary widely between Medicaid, exchange plans: study

A new analysis throws water on the potential benefits of narrow, or "high performance," networks.

Researchers at Georgetown University's Center on Insurance Reforms analyzed federal laws, state regulations and regulatory guidance on network adequacy and selected six states for case studies: Florida, Georgia, Kansas, New Mexico, Pennsylvania and Washington.

The study found huge variation between standards for physician networks between states, and volatility between Medicaid and individual market plans. This causes significant differences in access to in-network providers, according to the study.

This is especially true for people who may be enrolling in plans on the individual marketplaces, according to the study, as there is limited oversight for network adequacy. States are required to closely monitor networks for private Medicaid managed care plans.

“Having health insurance should give people the peace of mind that they can get the care they need,” said Andrea Ducas, senior program officer at the Robert Wood Johnson Foundation, which backed the study, in a statement. “One important dimension of that is having enough providers that accept your insurance. Policymakers can bring greater peace of mind to more people by ensuring that provider networks are adequate in size and scope of coverage.” 

Insurers argue narrower networks help manage costs due to a smaller list of provider contracts to manage as well as the ability to ensure plan members are seeking care from high-quality providers. Critics counter plans with narrow networks can make it far more difficult for people to get the care they need in-network.

For example, in Georgia and Kansas, Medicaid managed care plans must meet standards for time and distance to primary care providers, behavioral health providers and OB-GYNs. These standards, however, do not extend to qualified health plans on the states' exchanges.

The researchers found that state regulations guaranteeing access to primary care and rural health clinics are limited. Federal regulations in this area offer states flexibility, but most states simply enforce baseline requirements, according to the study.

In addition, there are no federal requirements to ensure the care provided is culturally competent, so access there is also lacking, according to the study.

A lack of standards makes it far more difficult for regulators to track and understand how well an insurer is in compliance with requirements, the researchers said. New Mexico is an example of a state that has updated its regulations to more effectively align with MCO standards.

Regulators should roll out additional oversight for provider networks, according to the study, and should embrace greater transparency around network challenges.