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What health reform means for the people of Illinois

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Wednesday, December 10, 2014

Why Narrow Networks are a Big Deal: A Discussion of Network Adequacy

A network is defined as the healthcare facilities, professionals, and suppliers that an insurance carrier has contracted with to include in a given health plan. Network adequacy is the extent to which a health plan has a satisfactory number of primary and specialty healthcare professionals that consumers can access in a timely manner.

The terms network and network adequacy are pretty technical words, so the average consumer may not know their definition, but a percentage of the population is even unaware of how to apply these terms to the process of purchasing a health insurance plan. According to a Commonwealth Fund survey of marketplace shoppers, 25% said they did not know the quality of the network for their health insurance plan. The survey results indicate that consumers may lack an awareness of how network adequacy impacts them on a personal level.

Consumer Problems with Network Adequacy

Consumer awareness is important, because network adequacy can have a tremendous influence on a patient's quality of care. For example, plans can include a hospital in their network, yet exclude doctors or specialists working at that hospital. As a result, patients may unknowingly receive care from an out-of-network doctor and be left with an exorbitant bill. This practice, in which consumers must pay the costs beyond the allowable amount determined by the health insurance company, is called balance billing. Sometimes the lists of healthcare professionals in a network are not even accurate, which may lead consumers to enroll in a plan that does not have their desired provider. Also, hospitals serving special populations, such as children, have reported difficulty being included in networks – preventing families from getting needed care at a reasonable cost.

Network Reforms Proposed

These issues may soon change. The National Association of Insurance Commissioners (NAIC) recently released a new draft model law for states, which has proposed some significant reforms. To begin with, hospitals would need to develop a process for alerting patients in cases where they may be seeking treatment from an out-of-network provider who happened to be working at an in-network hospital. In addition, insurance carriers would be required to update changes to their provider networks on a monthly basis and must make this information available online and in print form.

NAIC's draft model law also created the general recommendation for states to create sufficiency standards accounting for elements such as the amount of specialty services available, geographic accessibility, the number of providers, the wait time for receiving care, and the hours of operation for participating providers. NAIC gives states latitude in how they apply their sufficiency standards. However, NAIC does note that some states have chosen to adopt quantitative standards that set minimum numbers for providers for maximum travel times and maximum waiting times, among other metrics.

Changing Consumer Experiences for the Better

The reforms requiring insurance companies and healthcare providers to communicate accurate and timely information on healthcare networks are a much needed help for consumers who lack basic knowledge of their options (which may be due to the fact that they hate shopping for health insurance). Mandating more open lines of communication would simplify the process of finding and using health insurance. With readily available information, consumers would know what providers and hospitals are a part of their plan. Importantly, state actors are recognizing the significance of empowering consumers with knowledge, as the Illinois Department of Insurance recently released fact sheets on networks and out-of-network benefits.

Beyond improving communication with consumers, NAIC’s draft language on sufficiency standards would support consumers who have purchased a plan in having the ability to access the healthcare providers they need to stay healthy – without traveling great distances or waiting long periods of time. Advocacy needs to be done at the state level to guarantee that the sufficiency standards in place are in line with the intentions of NAIC’s draft model law and create quantitative metrics to determine a network’s strength.

Bryce Marable, MSW
Policy Analyst
Health & Disability Advocates


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