Network Adequacy: Ensuring Provider Access for Children

Health

Network adequacy has received a lot of attention in the last few months as people enrolled in health coverage through the new marketplaces and in Medicaid, and CHIP. Some families in Washington found out that a hospital they need and rely upon – Seattle Children’s Hospital – isn’t covered in their new plan. Understandably, this can be very distressing and cause people to immediately want to change their plan.

At the recent meeting of the National Association of Insurance Commissioners (NAIC), network adequacy concerns were discussed and commissioners agreed to focus on the issue in 2014. The NAIC’s current model law on network adequacy is woefully outdated and a fresh look is necessary. Commissioners from several states said they will address network adequacy through various means including a review of their current rules and regulations, commissioning a study of the issue, initiating formal rulemaking and/or holding a public hearing on the issue.

All of these actions will provide advocates in states a chance to weigh in on the issue and do what advocates do best: offering real-life stories about what families face when they are denied access to the providers and care their children need, as well as to provide ideas about how to ensure networks are adequate and meet the needs of those covered. Through meetings with state insurance commissioners, exchange/marketplace boards and directors, and health plan issuers, state advocates, and others can share the issues facing children in terms of network adequacy and help design state standards that serve the needs of children.

In order to assist advocates in states, First Focus, along with the Georgetown Center for Children and Families, the Children’s Hospital Association, Family Voices and the Children’s Defense Fund recently released an issue brief on network adequacy: Ensuring Adequate Marketplace Provider Networks: What’s Needed for Children. This brief, written by Michael Odeh from Children Now, explains why children need a robust provider network and how those networks can be developed and assessed over time.