Major differences in federal and state regulations for payer network standards are likely leading to care access inequities, according to a report by Washington, D.C.-based Georgetown University's Health Policy Institute.
The report, published March 30, analyzed federal laws and regulations surrounding the Affordable Care Act marketplace, Medicaid and Medicare Advantage. It also studied state marketplaces and Medicaid programs in Florida, Georgia, Kansas, New Mexico, Pennsylvania and Washington.
Key findings:
- The widespread use of "narrow" payer networks, where payers limit the number of providers patients can see under a plan, could limit patient care access.
- There is a major difference in standards for payers' physician networks across states and among Medicaid and marketplace plans in the same state. Individuals' ability to access in-network providers varies widely as a result.
- Marketplace enrollees have few federal protections. Federal regulations require states to oversee payer networks for Medicaid managed care organizations, but those requirements don't exist for marketplace-qualified health plans.
- State regulations protecting access to primary care providers and rural health clinics are limited. Federal regulations require health plans to contract with essential community providers and offer states flexibility, but most do not enforce standards beyond the minimum required.
- Cultural competency requirements are lacking. There are no federal requirements that payers provide enrollees with healthcare that meets their language or cultural needs. Most states have cultural competency requirements for managed care organizations, but far fewer have similar requirements for qualified health plans.
Recommendations to standardize network regulations and enforcement mechanisms:
- More oversight: Regulator reviews of qualified health plan provider networks should occur before they are marketed to consumers and after any change in the quantity or types of in-network providers. For primary care, mental health and substance use disorder services, reviews should include an assessment of whether enrollees can access providers within a specified maximum time or distance from their home, whether the plan meets a minimum ratio of providers to enrollees, and whether the plan satisfies a maximum appointment wait time for critical services. Network certification should not occur if these standards are not met. In states that do not comply, CMS should enforce.
- More attention to health equity: CMS should require qualified health plans in states with a federally facilitated marketplace to submit demographic data about communities in their service areas and how trained providers are to serve them. CMS should require a minimum percentage of primary and mental healthcare providers that speak the dominant language in communities with limited English proficiency and partner with HHS to assess discriminatory practices among providers.
- More access to essential community providers: President Joe Biden should continue to limit payers' ability to obtain exceptions from the minimum marketplace standard.
- More consumer protections: Federal regulations should add a requirement to qualified health plans to provide access to an out-of-network provider if the plan does not have a provider to meet an enrollee's health needs, grant a special enrollment period for enrollees with insufficient access to providers, and establish a consumer complaint system in coordination with state payer regulators to track and resolve enrollees' network access issues.
- More transparency: CMS should require payers to submit data about enrollees' use of out-of-network services stemming from the quantity and types of complaints they receive related to network access. Data should be made publicly available, and state and federal regulators should regularly review it to assess plan compliance with network adequacy standards. State-level regulators should assess and publish their current processes for evaluating network adequacy.
- More support for consumer decision-making: The federally facilitated marketplace should provide enrollees with information about their right to an adequate provider network and resources if they cannot find an in-network provider. The marketplace should evaluate and publish the results of the program to show network coverage.