In the first part of this series, we defined network adequacy and explained why it was critically important to ensure access to care for insured individuals. While most people agree that this issue is a top priority, there has been very little movement in some states to provide more consumer protections.
In Maryland
Maryland is one of fewer than 25 states that does not currently have quantitative standards to ensure network adequacy. In fact, Maryland is one of 14 states where the Insurance Commissioner has very little authority in this area. According to Maryland regulation, insurers determine their own network adequacy standards, the means in which they will achieve them, and corrective actions they will take if they determine that their networks are inadequate. They file these “availability plans” with the Commissioner, but the Commissioner has no authority to approve them or require improvements. Essentially, Maryland is what is called a “File and Use” state, meaning the insurers police themselves unless a consumer knows enough to file a complaint with the Maryland Insurance Administration. Maryland law enables insured individuals to go out-of-network at the in-network cost-sharing rate if there are not enough specialists in their network to provide an appointment without unreasonable delay or travel (Maryland Insurance Article 15-830d), but this must be approved by the insurance company prior to obtaining care. A member who goes out-of-network without this approval will likely be responsible for the out-of-network cost-sharing.
Other States
Recently, the National Association of Insurance Commissioners (the group of insurance regulators from around the country) spent 18 months drafting model legislation to address this issue because it was considered a nationwide problem. State regulators or advocates can use the model legislation to address network adequacy issues in their state by working with their legislature to pass the bill in their state. The Georgetown University Center for Health Insurance Reform has a great summary of the model legislation if you are interested. The model legislation doesn’t go as far as consumer advocates would have liked, by not requiring quantitative standards such as appointment wait time and travel distances. It does, through the drafting notes, encourage states to adopt quantitative standards that work for their state. The legislation includes a requirement that the Commissioner, rather than the insurer, determine the adequacy of a plan and requires the insurers to file “access plans” with the Commissioner for each plan sold.
Prior to the release of the NAIC model legislation, many other states passed legislation or promulgated new regulations establishing quantitative standards. Families USA has a great policy brief on this issue with state examples. Of note, California regulations require carriers to ensure that consumers can access a primary care doctor within 10 days, a mental health provider within 10 days, and a specialist within 15 days. Washington has similar regulations for primary care and specialist wait times.
Federal Government
In December 2015, the US Department of Health and Human Services released the draft issuer letter to all insurance carriers who want to sell Qualified Health Plans through the Federally Facilitated Marketplaces. Tim Jost, an NAIC consumer representative, has a comprehensive summary of the letter in the Health Affairs Blog. The letter explains that Qualified Health Plans will be required to meet quantitative network adequacy standards, either time and distance or ratio based, in order to be approved for sale. The federal government will rely on state regulators in states where there are acceptable standards, and in states where there are not acceptable standards, the feds will do the review and implement standards. The standards that HHS is proposing are similar to Medicare Advantage standards, which require that 90% of individuals are within 30 minutes or 15 miles to a mental health provider.
In Part III: What are Maryland Advocates Doing? And What Can You Do?