Assessing and Ensuring Health Plan Provider Network Adequacy
February 26, 2010
An insurer’s provider network can influence the quality of care it can provide and its ability to control costs. On the one hand, narrow provider networks may allow health plans to control costs and use but may limit access to providers; on the other hand, broad provider networks do not restrict access to providers but may constrain plans’ ability to control costs and use of services. For health plan enrollees, the number, type, location, and availability of network providers affect access to timely and quality care. Ensuring network adequacy and providing information about the network is especially important when patients face higher cost sharing or different coverage rules when going outside a plan’s network. To ensure access to services, government purchasers and regulators require health plans’ networks to meet adequacy requirements. Current requirements for health plans’ networks—including the number, type, and location of providers—vary by type of plan and by jurisdiction. This session addressed how networks can affect the cost and quality of health care and examined network adequacy requirements, metrics, and oversight.
Danielle Moon, JD, Acting Director, Medicare Drug & Health Plan Contract Administration Group, Centers for Medicare & Medicaid Services; David Parrella, Consultant, Alicia Smith and Associates (Washington, DC); Brian Haile, Deputy Director, Tennessee Division of Benefits Administration (Nashville)