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Network Adequacy:
Resources for Advocates

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.

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

What Are Other States Currently Doing?

Surprise Medical Bill Resources

Health Equity Resources