The Affordable Care Act directed the Secretary of Health and Human Services to establish criteria for certification of qualified health plans, to include (1) ensuring a sufficient choice of providers and (2) providing information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers. 45 CFR 156.230, entitled network adequacy standards, requires qualified health plans to maintain a network sufficient in number and types of providers (including mental health and substance abuse providers) to assure all services will be accessible without unreasonable delay.
To expand on the Federal regulation requirements, definitions for Network Adequacy commonly contain the following elements:
The ability of the health plan provider networks to –
- deliver the right care by having a sufficient number of in-network primary care and specialty providers
- offer timely access to care
- allow enrollees to receive care without unreasonable travel
The last element is not just about rural settings, in which enrollees might need to drive hours to receive care. Urban enrollees can face challenges in receiving care if providers are not accessible via common forms of public transportation.
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Expanded Health Coverage Puts Strain on New and Existing Providers
Network adequacy has taken on greater importance with the passage of the Affordable Care Act. The individual mandate means more people have health insurance, which removes lack of insurance as a primary barrier to the receipt of care. These additional individuals with insurance, including individuals receiving coverage via expanded Medicaid, put additional pressures on existing and newly formed provider networks.
Meeting Network Adequacy Requirements
Determining network adequacy can seem challenging, but is not with the right strategy. The list below outlines how to determine if a provider is meeting its network adequacy requirements
Confirm provider roster
First and foremost, determining network adequacy involves determining who is in the network. News stories abound of inaccurate provider network rosters. Pulling a sample of providers and calling them can ensure whether the providers are or are not part of the network.
Calculate enrollee travel time
Once an accurate network roster is in hand, an analysis of enrollee addresses matched to provider addresses can determine potential travel distances for enrollees to see either primary care or specialty providers.
Determine timeframe for new appointments
Finally, calls to providers to set up appointments can ascertain whether providers are accepting new patients and how long it takes to set up an appointment.
These three steps will answer whether and to what extent a provider network has a sufficient number of providers to offer timely access to care with reasonable travel.
Speak With an Expert About Network Adequacy
The compliance experts at IntegrityM have experience working with government provider networks and have the expertise to determine if your network meets state and federal standards. Call us today at (703) 535-1400 or contact us online for more information.