Quality Over Quantity? New Medicaid Network Adequacy Rules Illuminate Disparities Among Insurance Program Standards

One of the goals of the Affordable Care Act (ACA) was to fill the gap in coverage options for people who don’t have access to employer-sponsored coverage and are ineligible for public programs. Medicare was created in 1965 to help retirees, while Medicaid was created to cover low-income and disabled individuals. CHIP was enacted in 1996 to help cover children. But even with those programs, on the eve of the ACA, as many as 50 million people lacked insurance because they couldn’t get it through work and didn’t qualify for Medicare, Medicaid, or CHIP.

The ACA’s insurance reforms have led to dramatic gains in access to coverage. But the kind of coverage you get – and in particular your access to health care services – can very much depend on which program you’re eligible for. This disparity has become ever more apparent because of the varied approaches to provider network adequacy standards across the Medicare, Medicaid, and ACA markets.

New federal rules set new minimum standards for Medicaid managed care plans, as outlined in a recent report by our colleagues at Georgetown’s Center for Children and Families. These new standards establish minimum requirements to ensure narrow networks don’t prevent access to providers and essential health services. Specifically, the new rule for Medicaid and CHIP managed care plans requires states to set quantitative standards for network adequacy, and monitor their implementation.

If you’re enrolled in an ACA marketplace plan or Medicare Advantage plan, do you get the same protections? Not exactly. The table below compares how the three different programs tackle network adequacy.

Network adequacy standards Medicaid/CHIP managed care plans Federally Facilitated Marketplace (FFM) Medicare Advantage
Top-level analysis States are required to set quantitative network adequacy standards for time and distance in primary care, OB/GYN, behavioral health, adult and pediatric specialists, hospital services, pharmacy, pediatric dental, and LTSS services requiring travel. Networks required to be “sufficient in number and types of providers” so that “all services will be accessible without unreasonable delay” with no quantitative standards. Federally mandated quantitative standards for provider sufficiency, travel time, and distance.
Quantitative access requirements Requires states to establish quantitative time and distance standards, considering adequacy factors such as expected enrollment, health needs of enrollees, geographic location, language proficiency, and means of transportation. None Minimum number of providers and minimum provider ration; maximum travel time and distance.
Provider directory requirements Must link to provider directories on websites; directory must be updated monthly, including whether or not the provider is accepting new patients. Must include cultural/linguistic capabilities. Must link to provider directories on Marketplace website; directories must be updated monthly, including whether or not the provider is accepting new patients; no language transparency requirements. Plans can change provider networks at any time. Must disclose provider network upon enrollment or renewal of enrollment. Current directories available upon request, as well as on website (Medicare.gov not required to link to provider directories). Plans can change provider networks at any time.
Sources: Center for Children and Families, Medicaid/CHIP Managed Care Regulations: Network Adequacy and Access to Services, 2016; Kaiser Family Foundation, Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations, 2015
So what do these differences mean for consumers? Quantitative standards, a mandate of Medicare Advantage plans and Medicaid/CHIP managed care plans, define access in a tangible, measurable manner; the FFM’s qualitative standard of access without “unreasonable delay” means that adequacy is in the eye of the beholder. While enrollees in the different programs represent different age groups and income levels, all consumers deserve the same basic level of network adequacy, regardless of the stamp on their insurance card. While searching for a doctor accessible by public transportation, or waiting anxiously for an appointment opening, the holes in the federal safety net can start to show.Source: Kaiser Family Foundation, Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations

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