Ensuring Compliance with Network Adequacy Standards

Lessons from Four States

Two young women fill out an enrollment form.

Insurers provide increasingly narrow provider networks which can limit patient access to care. Current regulations do little to prevent this, but researchers find there are best practices to ensure consumers have adequate access to health care providers.

The Issue

Insurers increasingly trim the number of providers within networks to lower their costs, enabling them to better compete for customers, but they still must maintain network adequacy.

Key Findings

  • States can assess the adequacy of provider networks with key metrics including geographic access standards, provider-to-enrollee ratios, and timely access to care standards.

  • There are network adequacy regulatory gaps that will persist into the future.

  • No appropriate bright-line standard for network adequacy currently exists.

Conclusion

States have promising regulatory practices to ensure network adequacy, but there are few one-size-fits-all solutions to this increasingly common problem.

About the Urban Institute

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.