Tougher network adequacy rules sought

Providers and consumer advocates say a proposed model law on the adequacy of health plans’ provider networks needs to be considerably strengthened.

The draft, resulting from numerous meetings with stakeholders, says health plans must maintain networks that provide customers access to all medical services without “unreasonable delay.” It also would require health plans to update their provider directories at least monthly.

The National Association of Insurance Commissioners is seeking comments from stakeholders about the proposal until Jan. 12. The model law is not expected to be completed until next year. If adopted by state legislatures, the rules would apply to all health plans.

Controversies over provider networks have erupted across the country as insurers have moved to narrow-network plans over the past few years. Providers have sued over being excluded from plans, and consumers have complained about lack of access to particular hospitals and doctors, including specialty facilities. There also have been widespread complaints about plans disseminating inaccurate directories of the providers participating in their networks.

Last week, California insurance regulators issued critical reports about directories published by Anthem Blue Cross and Blue Shield of California.

Providers and consumer advocates want the model law to be tougher. The draft sets no measurable standards for defining network adequacy, leaving it up to plans to come up with the criteria, said Stephanie Mohl, senior government relations adviser for the American Heart Association, who also serves as one of the NAIC’s consumer representatives.

Consumer advocates also want the directory provisions strengthened, including requiring insurers to provide information about how using different tiers of providers would affect consumers’ out-of-pocket costs.

Mohl would like to see a requirement that physicians employed by a hospital and its emergency room doctors be considered in-network providers when the hospital is in a plan’s network. “When it’s an emergency, the consumer literally has no choice what hospital they go to and who they’re seen by in the emergency room,” Mohl said.

Lynn Quincy, associate director of health reform policy at Consumers Union, praised the NAIC for its open process in drafting the model law, but said the proposal is “a fairly conservative product” because the group was trying to make all its stakeholders happy.

The proposal requires that plans provide customers with access to medical services without “unreasonable delay.”