Issue Briefs | Aug 11, 2013

ACA Implications for State Network Adequacy Standards

Georgetown University Health Policy Institute – Sally McCarty and Max Farris

This brief, prepared by the Georgetown University Health Policy Institute, explores some of the discrepancies that can arise with varying network adequacy standards and provides examples of how some states have resolved such issues. Network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract.

States have taken different approaches in regulating the adequacy of health plan networks based on their state-specific market. States have a variety of options available to maintain robust health insurance markets by balancing access needs with the goals of controlling costs and attracting a healthy number of insurers. Appendix A serves as a comparison table of different network adequacy standards and requirements.  Appendix B provides a narrative description of network adequacy standards in California, Colorado, Delaware, Hawaii, Maryland, Minnesota, Montana, Texas, Vermont, Washington, and the Federally-facilitated Marketplace.