Corlette and other health policy analysts at Georgetown University have reported on the current status of state provider network adequacy oversight in a paper distributed by the Commonwealth Fund.
The Patient Protection and Affordable Care Act of 2010 (PPACA) does require a plan sold through a PPACA public exchange to offer “‘a network that is sufficient in number and types of providers’ so that ‘all services will be accessible without unreasonable delay,’” the analysts write, quoting the text of the statute.
But PPACA itself does not include any quantitative standards, and the U.S. Department of Health and Human Services (HHS) lets states implement and enforce their own adequacy standards, Corlette and her colleagues write.
Today, the analysts say, 23 states and the District of Columbia set no quantitative standards for exchange plan provider networks.
Eleven states impose quantitative provider network standards on some exchange plans, and 16 states impose quantitative standards on all exchange plans.
In the states with quantitative standards, 23 set standards for the maximum amount of time or distance an enrollee must travel to get covered services, and 11 require that enrollees be able to get appointments with certain types of doctors, such as primary care doctors or nephrologists, within a specified length of time. In Montana, for example, enrollees must be able to get urgent care within 24 hours.
Ten states require plans to offer a minimum ratio of various types of providers to enrollees. One, Nevada, requires a plan to have one cardiologist for every 7,500 enrollees.
Some states have tried to help consumers assess network adequacy by setting provider directory update standards, the analysts say.