Assessing Federal and State Network Adequacy Standards for Medicaid and the Marketplace

A nurse takes a young girl's blood pressure.

Federal and state standards—enacted to ensure that people who get their health coverage through Affordable Care Act Marketplaces, Medicaid, or Medicare Advantage plans have sufficient access to in-network primary and specialty care providers—are severely lacking. Patients may struggle to access needed healthcare as a result.

The Issue

For health insurance to be meaningful, enrollees must have access to providers that can meet their healthcare needs. However, there is little consensus over what network adequacy means in practice, what standards should be used to assess it, and how those standards should be enforced. 

Key Findings

  • There is dramatic variation in standards for health insurers’ physician networks across states and among Medicaid and Marketplace plans in the same state. Individuals’ ability to access in-network providers varies widely as a result.

  • Marketplace enrollees have few federal protections. Federal regulations require states to oversee insurer networks for Medicaid managed care organizations, but no such requirements exist for Marketplace qualified health plans (QHPs).

  • State regulations protecting access to primary care providers and rural health clinics are limited. Federal regulations requiring health plans to contract with essential community providers, like primary care providers and rural health clinics, offer states considerable flexibility, but most states do not enforce standards stronger than baseline requirements.

  • Cultural competency requirements are lacking. There are no federal requirements that individuals be able to access healthcare that meets their language or cultural needs. Although most states have cultural competency requirements for managed care organizations, far fewer have similar requirements for QHPs.

Conclusion               

Federal standards for and oversight of network adequacy are minimal, and state-level regulation is patchwork and inconsistent. As a result, timely access to needed health services is largely a function of where an individual lives and is by no means guaranteed. Researchers identify policies and practices to help health plans ensure their networks include the number and mix of providers enrollees need.

About Georgetown University's Health Policy Institute

The Center on Health Insurance Reforms at Georgetown University's Health Policy Institute is a nonpartisan, expert team of faculty and staff dedicated to conducting research on the complex and developing relationship between state and federal oversight of the health insurance marketplace.