Network Adequacy: Seeking Balance

September 26, 2014

Some new health plans sold in the insurance marketplaces are offering consumers networks that exclude certain doctors, hospitals and other medical providers. While some claim that these networks hamper provider access and choice, others contend that this approach, if done the right way, helps consumers by creating competition and controlling costs.

The federal and state governments are now considering how to best regulate provider networks. The National Association of Insurance Commissioners (NAIC) is finalizing its update of model regulations for states, while the Department of Health and Human Services (HHS) is deciding what federal role, if any, it will assume. HHS already regulates networks for Medicare Advantage health plans, and some say this could serve as a model for health plans sold in marketplaces. Speakers include:

  • Mike Leavitt, founder and chairman, Leavitt Partners, former Utah governor and HHS Secretary under George W. Bush, addressed the issues surrounding network adequacy, and his preference to regulate networks at the state level.
  • Stephanie Mohl, senior government relations advisor, department of advocacy, American Heart Association, talked about research that assesses networks in a handful of states, and about challenges in making sure patients have access to specialty care.
  • Jolie Matthews, senior health and life policy counsel, NAIC, discussed model network regulations that the NAIC may release in November. She will also talk about how insurance commissioners are handling the issue across the country.
  • Gretchen Jacobson, associate director, Kaiser Family Foundation’s Program on Medicare Policy, described the current network adequacy standards for the Medicare Advantage program, which some see as a model for marketplace plans.

Two additional experts will join in the Q&A:

  • Steven Shapiro, executive vice president, chief medical and scientific officer, president of the physician services division, University of Pittsburgh Medical Center
  • Marc Barclay, vice president of provider networks and contracting, BlueCross BlueShield of Tennessee

Moderator: Ed Howard, executive vice president, Alliance for Health Reform

Follow the briefing on Twitter: #NetworkAdequacy

The event was sponsored by the nonpartisan Alliance for Health Reform, with the support of the University of Pittsburgh Medical Center and the Blue Cross Blue Shield Association
If you were unable to attend the briefing, here are some key takeaways:

    • Regulators should move slowly in developing an approach to allow sufficient time to understand early consumer experiences, said Mike Leavitt. He added that, as economic pressure is brought to bear, networks become more efficient.


    • Access to specialty physicians and facilities varies by region and health plan, according to a new Avalere study commissioned by the American Heart Association. Stephanie Mohl noted that one plan network covers 8 percent of certain specialty physicians, while another covers 83 percent. She emphasized the need for transparency, standardization, and up-to-date directories of professionals.


    • Health plans cannot keep directories of medical providers up to date without the help of providers, who often don’t inform health plans when their work situation changes, said Marc Barclay.


    • The NAIC is hoping to complete its update of network adequacy model regulations by November or early December, said Jolie Matthews. If the NAIC addresses tiered networks, its recommendations will likely be limited to disclosure transparency, she said. Provider standards should be regulated at the state level, and not at the federal level, she said.


  • Federal network standards currently exist for Medicare Advantage plans, said Gretchen Jacobson. In 2015, she noted, if plans change networks mid-year, they must notify CMS 90+ days in advance, providers 60+ days, and enrollees 30+ days in advance.


Full Transcript (Adobe Acrobat PDF)

Speaker Presentations

Stephanie Mohl Presentation (Adobe Acrobat PDF)
Jolie Matthews Presentation (Adobe Acrobat PDF)
Gretchen Jacobson Presentation (Adobe Acrobat PDF)

Event Details

Agenda (Adobe Acrobat PDF)
Speaker Biographies (Adobe Acrobat PDF)

Event Resources