New Report on ACA Implications for State Network Adequacy Standards

The ACA provides consumers, particularly those in the individual market, with access to a wider range of health insurance benefits than has ever before been available. Whether or not consumers will be able to easily access those benefits depends on how closely states adhere to, or build upon, the network adequacy standards set out in the ACA’s implementing regulations.

The ACA requires that Qualified Health Plan (QHP) networks be sufficient in numbers and types of providers, including providers that specialize in mental health and substance abuse services, to ensure that all services covered under the QHP will be accessible without unreasonable delay.  While the ACA provides a general framework to address the adequacy of QHP networks, the law and its implementing rule and guidance make the states responsible for assuring that network adequacy is achieved for the benefit of consumers.   States, in turn, take different approaches in regulating the adequacy of health plan networks, at least in part due to the need for states to maintain robust health insurance markets by balancing access needs with the goals of controlling costs and attracting a healthy number of insurers.

Last Friday, the Robert Wood Johnson Foundation’s State Health Reform Assistance Network released a brief prepared by researchers at CHIR that compares several state network adequacy requirements to the ACA’s network standards applicable to QHPs.  The paper focuses on network adequacy standards in place in California, Colorado, Delaware, Hawaii, Maryland, Minnesota, Montana, Texas, Vermont, Washington, and in the Federally Facilitated Marketplace.  In particular, the paper explores how the ACA and several states deal with issues such as specific mileage and wait time limits, consumer access to essential community providers, and consumer access to provider directories, as well as how state regulation of network adequacy varies depending on the type of health insurance product. You can check out the brief here.

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