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Provider network storm gains strength

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Two national groups that shape insurance laws and regulations are both finishing proposals that could affect minimum standards for major medical plan provider networks.

At the National Association of Insurance Commissioners (NAIC), the Health Insurance and Managed Care Committee has approved revisions to the NAIC’s Managed Care Plan Network Adequacy Model Act.

The NAIC’s executive committee and its plenary, the group that includes all NAIC voting members, could vote on the model revisions later this month, at the NAIC’s fall meeting in National Harbor, Md.

At the National Conference of Insurance Legislators (NCOIL), the Health, Long-Term Care and Health Retirement Issues Committee is preparing to vote on a Proposed Model Act Regarding Network Adequacy and Use of Out-of-Network Providers Nov. 12.

The NAIC and NCOIL began their projects in response to complaints, especially from providers, about the narrow provider networks some insurers have been using to hold down the cost of coverage, and to complaints from consumer groups, and insurance agents and brokers, about patients who thought they were using in-network care getting bills for out-of-network services.

See also: More skirmishes from the provider network war

Both proposals would set provider directory standards, requirements for telling patients when providers are out-of-network, and network adequacy requirements.

The NCOIL proposal would require regulators to actively review and approve networks every three years.

Similarly, the NAIC proposal would flesh out existing adequacy standards.

Representatives from America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association have written to say they like the NAIC draft and oppose efforts to apply the same high adequacy standards to all tiers.

Representatives from patient and provider groups have written to say they want to see tougher standards, including provisions requiring an active provider network adequacy review process.