The majority of Americans have a private health insurance plan. Medical insurance sets up a network of providers (contracted physicians, other providers, and facilities) that provide care to subscribers.
A provider network is considered “inappropriate” if there are not enough providers nearby for a registrant to receive timely care. You may seek medical attention.
Most states say they validate plans on an annual basis before approving them for sale. However, the criteria used to assess network adequacy, such as maximum latency and sufficient choice of providers, varied by state.
What GAO found
Provider network adequacy refers to the health plan’s ability to deliver promised benefits to its subscribers by providing reasonable access to a sufficient number of in-network providers. Poor networks make registrants more likely to seek care from out-of-network providers, which can be costly. State agencies and the Department of Health and Human Services (DOL) are each responsible for overseeing private healthcare plans, including, in some cases, specific requirements related to the adequacy of provider networks. These surveillance practices varied.
- Officials in 45 of the 50 states that responded to the GAO survey (including the District of Columbia) reported taking various actions to oversee the adequacy of individual and group health insurance provider networks. did. For example, officials in 32 states reported reviewing the health insurance provider’s network before marketing plans were approved, and officials in 23 states reviewed their plans if there were changes to the network. . Officials in 44 states used at least one criterion to assess network adequacy, he reported in the GAO study. Examples of criteria include maximum time or distance to the provider, maximum waiting time to see the provider, etc.
- The Center for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services oversees the adequacy of a provider network of most eligible health insurance (QHP) offered on federally facilitated exchanges. CMS oversight activities include annual and targeted reviews of the QHP network, as well as reviews of the Provider Directory, the plan’s list of in-network providers and facilities. For example, as part of the agency’s annual review of her QHP for the 2023 Plan, a CMS representative asked her GAO to compare issuer data on the provider network to her CMS’s network adequacy criteria. Told.
- Although the DOL generally does not have the authority or standards to enforce network adequacy for private employer-sponsored group health plans, the DOL does review compliance with equality requirements for mental health and substance use disorders. is being implemented. DOL will enforce these requirements by conducting reviews to ensure that limits on mental health and substance use disorder benefits are less restrictive than limits on medical/surgical benefits.
Although there is no comprehensive information on the overall adequacy of provider networks, the state and CMS have identified issuers that do not comply with network adequacy standards. The information also indicated that access to certain provider specialties, such as mental health and pediatrics, may be restricted. States and stakeholders also report interrelated factors that may contribute to inadequate networks: provider shortages, challenges in contracting providers, and geography. These interrelated factors were consistent with the literature. For example, a lack of providers can lead to inadequate networks. This can be particularly difficult in rural areas as such shortages limit the number of available providers that issuers can contract with.
Why GAO did this study
The majority of Americans, or about two-thirds of Americans, have health insurance through private health plans. A health plan establishes a provider network (doctors, other health care providers, and facilities contracted by the plan) to provide health care to its policyholders. A provider network may be inadequate if the network lacks the number of providers or facilities that provide care to policyholders. Poor networks can impact the ability of enrollees to access care in a timely manner.
The Consolidated Appropriations Act of 2021 includes provisions for GAO to review the adequacy of provider networks in individual and group health plans. This report describes (1) the state, CMS, and DOL oversight of adequacy of provider networks; (2) Known adequacy of individual and group health insurance provider networks.
For this report, GAO (1) reviewed guidance and reports from CMS and DOL. (2) conducted a survey and received responses from 49 states and the District of Columbia regarding the problems the states experienced with the adequacy of their surveillance practices and networks; (3) Interviews with stakeholders such as CMS, DOL, selected states, and the American Medical Association. (4) reviewed the available literature that evaluated the adequacy of provider networks;
GAO provided a draft of this report to the Department of Health and Human Services and DOL. Both agencies provided technical comments and were incorporated where appropriate.
For more information, please contact John E. Dicken ((202) 512-7114) or DickenJ@gao.gov.
