Patient Support & Advocacy

Physicians outline 6 key provisions for network adequacy

Physicians, hospitals and other health care providers urged the National Association of Insurance Commissioners (NAIC) in a letter (log in) sent Monday to adopt model legislation that would give patients access to the care and physicians they need.

The letter includes six key provisions that would serve as a template for many state policymakers considering revision of their network adequacy standards. More than 115 groups signed onto the letter, sent to Kansas Insurance Commissioner Sandy Praeger and Wisconsin Commissioner Ted Nickel, who chair key committees at NAIC.

The six provisions of model network adequacy legislation are:

  1. Provider networks must include a full range of primary, specialty and subspecialty providers for all covered services for children and adults.
  2. Regulators must actively review and monitor all networks using appropriate quantitative and other measurable standards. Determinations of network adequacy must be the responsibility of regulators, utilizing strong quantitative and objective measures that take into consideration geographic challenges and the entire range of consumers’ health care needs. 
  3. Appeals processes must be fair, timely, transparent and rarely needed. Model legislation must make clear that out-of-network arrangements and procedures are not an acceptable alternative to plans having an adequate network. 
  4. The use of tiered and narrow provider networks and formularies must be regulated. Specific patient protections must be included in the Model Act for networks that are tiered or are limited in scope and number of providers in order to prevent unfair discrimination based on health status. 
  5. Insurers must be transparent in the design of their provider networks. It is critical that consumers have clear information regarding the design of their plan’s provider network. 
  6. Provider directories must be accurate and up-to-date. Consumers must have access to robust provider directories to enable them to determine which providers are in-network when they purchase their plans, and, in the event their medical needs change, when they need new providers. 

“By adopting provisions consistent with the principles outlined in this letter, we believe lawmakers and regulators can adapt the model act to establish reasonable, meaningful standards, while still allowing for market flexibility and choice,” the letter said.

The letter aligns with policy adopted at the 2014 AMA Interim Meeting, which calls for health insurers to make any changes to their provider networks before the open enrollment period gets underway each year. Implementing changes to provider networks at this time will help prevent patients from being stuck with plans that drop their physicians after they already have enrolled.