Advocate Resources
Network Adequacy

What is Network Adequacy?

Simply, the idea that a health plan's provider network is adequate to deliver benefits promised under the plan. In addition, consumers need to be able to reliably and easily understand the relative adequacy between plans and be able to identify which providers are in-network and which are out-of-network when consuming care.

The Need for Improved Network Adequacy

At a time when networks are narrowing and consumers are facing greater out-of-pocket costs, consumers need a basic level of assurance that the plan they are buying has the ability to deliver promised benefits. Provider directories—which form the basis for any assessments of network adequacy—have been shown in multiple studies to be riddled with errors. Surprise balance billing—unexpected charges from out-of-network providers—is an issue closely related network adequacy and provider directory problems. Furthermore, a nationally representative survey that shows that when consumers experience a problem related to inadequate networks, they do not know where to complain. So regulators are not seeing many of these consumer problems.

NAIC Model Law

The National Association of Insurance Commissioners approved a new model law in November of 2015 which is expected to engender discussions of new protections in many states.

• Link to the Model Law
• NAIC Summary of Project History and Section-by-Section Summary of Revisions
• Multi-Organizational letter to NAIC commissioner and committee members

Specific provisions worth highlighting include:

• Protections against surprise medical bills (also known as balance bills) for emergency and planned services at in-network facilities when care is delivered by out-of-network providers.
• Requirements that the state insurance commissioner, not each individual health insurance plan, will determine if provider networks are adequate.
• Standards for the accuracy of provider directories that allow the public to report directory inaccuracies to health plans and require insurers to periodically audit their directories.
• Continuity of care protections for enrollees who are in the middle of an active course of treatment, if their providers leave or are removed from their health plan’s network.

Advocacy Tools

Network Adequacy Consumer Principles

• Consumers Union: Network Adequacy Standards and Transparency Needed to Protect Consumers
• Community Catalyst: Finding Common Ground: Network Adequacy Principles
• American Heart Association: Ensuring Access to Quality Care: Network Adequacy
• Families USA: A state-by-state fix for network adequacy issues?
• Families USA: NAIC Network Model Act: Summary of Key Provisions

What Are Other States Currently Doing?

• Families USA: Standards for Health Insurance Provider Networks: Examples from the States
• Center on Health Insurance Reforms: Balance Billing: How Are States Protecting Consumers from Unexpected Charges?
• Maryland Health Benefit Exchange: DRAFT 2017 Letter to Insurers Seeking to Participate in Maryland Health Connection
• Commonwealth Fund (Georgetown Univ. Health Policy Institute): Implementing the Affordable Care Act: State Regulation of Marketplace Plan Provider Networks

Surprise Medical Bill Resources

• Healthcare Value Hub: The Hub's surprise medical bill resources page.
• Consumers Union: Getting Started on Surprise Medical Bills: An Advocate’s Guide
• Consumers Union: State-specific complaint tool and national survey

Health Equity Resources

• Families USA: Network Adequacy and Health Equity: Improving Private Health Insurance Provider Networks for Communities of Color