Implementing the Affordable Care Act: State Regulation of Marketplace Plan Provider Networks

By Justin Giovannelli, Kevin Lucia, and Sabrina Corlette

The prevalence on the Affordable Care Act’s health insurance marketplaces of plans with relatively limited provider networks has attracted substantial interest among consumers, policymakers, stakeholders, and the media. A “narrow network” plan may offer value to consumers, if it pairs a comparatively lower premium with meaningful access to a sufficient array of providers. But these plans also pose risks. A network that is too narrow may jeopardize consumers’ ability to obtain needed services or expose them to expensive charges for out-of-network care. And if a plan’s network design and list of providers isn’t clear, it may be impossible for consumers to judge whether the plan they’re shopping for is right for them.

The ACA created the first federal standard for network adequacy in the commercial insurance market for plans offered through the marketplaces. As with other consumer protections found in the health law, however, the ACA’s network standard constitutes a floor, not a ceiling. States have first responsibility for enforcing the network rules and have flexibility to set their own standards if they chose.

In a new issue brief for The Commonwealth Fund, Justin Giovannelli, Kevin Lucia, and Sabrina Corlette examine network adequacy standards for marketplace plans in the 50 states and District of Columbia. They identify state requirements in effect at the outset of marketplace coverage in January 2014 and explore the extent to which those standards evolved for 2015. You can read the brief here.

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