Regulation of Health Plan Provider Networks
A new policy brief from Health Affairs and the Robert Wood Johnson Foundation offers an overview of state and federal actions that address network standards and provider directories on the Affordable Care Act’s (ACA’s) health insurance Marketplaces, focusing on the rules that govern plans sold there. Studies have found that in the first two years of the ACA’s existence, narrow network plans constituted nearly half of all Marketplace offerings. While limited network plans, pairing low premiums with a restricted set of high-quality providers, are likely to offer consumers value and access to care, these plans can also pose risks, and anecdotal complaints about networks have proliferated. As a result, lawmakers and regulators have devoted significant attention to determining how networks should be regulated to ensure they are adequate and transparent.
Topics covered by this policy brief include:
- What’s the background? This section of the brief explains how provider networks are set up, operate, and are regulated. It also defines network adequacy, tracing the evolution of state regulations of network adequacy, and details the ACA’s network provisions and the implementation of the ACA’s network requirements.
- What’s the debate? For both consumers and insurers, the value of limited provider networks is in the eyes of the beholder, and network plans present tradeoffs for both providers and consumers. The brief contrasts the views of proponents of so-called qualitative standards, who claim that adequacy standards are too prescriptive, with those supporting the development of quantitative standards. This section of the brief also discusses ways to apply and enforce both frameworks and how states and federal officials can support these efforts.
- What’s next? In 2015 the National Association of Insurance Commissioners (NAIC) revised a model law it had developed in the 1990s to regulate network advocacy, endorsing a qualitative standard for judging network sufficiency. Despite the NAIC’s efforts to get a majority of state legislatures to adopt it within three years, few have passed it so far. The brief notes that should this continue, federal regulators are likely to take steps to strengthen network requirements for Marketplace plans.
NOTE: This Health Policy Brief is based on the author’s ongoing research at Georgetown University Health Policy Institute supported by The Commonwealth Fund.
About Health Policy Briefs
Health Policy Briefs are aimed at policy makers, congressional staffers, and others needing short, jargon-free explanations of health policy basics. The briefs, which are reviewed by experts in the field, include competing arguments on policy proposals and the relevant research supporting each perspective.
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About Health Affairs
Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print and online, with additional Web First papers and health policy briefs published regularly at www.healthaffairs.org. Read daily perspectives on Health Affairs Blog and customize the content you want to see in Health Affairs Alerts.
About the Robert Wood Johnson Foundation
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.