New standards could expand provider networks


As health insurers' provider networks get more narrow, many states adopt standards to ease consumer concerns about limited selections of doctors and hospitals, reports The New York Times. For instance, in New York, doctors must tell patients prior to treatment what insurance they accept. And if needed, the patient can look for providers outside the network at no additional cost.

Another state, Washington, in April adopted a new rule requiring insurers incorporate certain adequacy standards in their provider networks, FierceHealthPayer previously reported. Those changes effectively require insurers to broaden their networks.

During this past open enrollment period, states found many consumers purchased healthcare reform plans based on price alone, without realizing the plans came with narrow networks.

"I heard from many consumers who were upset to find their health plan no longer included their trusted doctor or hospital," Washington Insurance Commissioner Mike Kreidler told the Times. "Some people discovered this only after they had enrolled."

To avoid these network surprises, federal officials are developing new standards that will be similar to those used to determine whether Medicare Advantage plans have enough doctors and hospitals in their networks. Such standards regulate the minimum number of primary care doctors a health plan must include, depending on various population factors, notes the Times.

When insurers submitted their applications to sell health plans on the federal marketplace last month, they had to list every doctor, hospital and pharmacy in their networks. Under the new standards, insurers must have contracts with at least 30 percent of essential community providers that treat low-income people. Insurers also must have networks that are sufficient in number and type of providers to avoid unreasonable delays in care, notes the Times.

For more:
- here's the NYT piece

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