Network Adequacy

Network Adequacy for Qualified Health Plans

Federal regulations require that a Qualified Health Plan carrier (health insurance company) “Maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services. This is to assure that all services will be accessible without unreasonable delay.” This is Network Adequacy.

Nevada Revised Statute 687B.490 states that “A carrier that offers coverage in the group or individual market must, before making any network plan available for sale in this State, demonstrate the capacity to deliver services adequately…”

For the health plan you signed up with through the Federal Exchange (Marketplace) or directly with a health insurance company, this means that your health insurance company should have an adequate number doctors, hospitals, and pharmacies in their network. This is so you can get the services you need in a reasonable time frame.

This implies that your health plan should be able to deliver the right care, when you need it, without you having to travel too far to get it. The plan should have a sufficient number of primary care and specialist doctors as well as medical facilities. Lack of this is becoming a problem in Nevada, particularly if you don’t live in Clark County.

The number of health insurance companies offering coverage in Nevada dropped substantially in 2016.

Humana, Assurant and the Nevada Health Co-op all stopped issuing policies here. Some of the companies remaining now have ‘narrow networks’. This means there are not very many Providers are on their list. They do this to save money. The smaller their Provider list, the less it costs them.

And the adequacy problem is not just with the insurance companies. Provider and medical facilities are now turning down new patients if they purchased their health plan through the Federal Exchange. Recently, a large local medical group said they will no longer accept any patients who have coverage through the Exchange.

As another example of network inadequacy, we are seeing more and more instances of patients being balance billed for out-of-network services. In addition, they didn’t even know they had received a bill.

Case in point:

My clients tell me they had a routine surgery scheduled with an in-network hospital, with an in-network surgeon.  They even double checked with the insurance company to make sure they had prior authorization. Although, post-surgery they receive bills from out-of-network Providers like anesthesiologists, pathologists, and radiologists and for services like lab tests sent to an out-of-network lab. The insurance company doesn’t want to pay them saying it’s out-of-network. The hospital won’t cover them because they say that’s how it works. They have no control what networks all their doctors’ service providers are in. The patient then gets stuck with the bills.

Network adequacy or inadequacy, as the case may be, is becoming more of an issue each year with the Affordable Care Act.