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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

Health Reform’s Network Adequacy Standards: New Report, Hill Day Session Announced

August 27, 2013 | Health Insurance Exchanges | Comments
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The extent to which healthcare services are available to millions of Americans purchasing health insurance through state-based marketplaces under health reform will depend in large part on the adequacy of their health plans’ provider networks. A new report issued by the Robert Wood Johnson Foundation (RWJF) in partnership with the Georgetown University Health Policy Institute sheds light on how states are managing network adequacy issues.

Network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract. The Affordable Care Act includes a number of network adequacy standards that, taken together with essential health benefits requirements, will determine what care is covered and how easily it will be obtained.

Guidance issued by the Obama Administration defines the minimum network adequacy standards that plans must meet, including a requirement that provider networks include sufficient numbers and types of mental health and addiction treatment professionals to ensure that all services will be accessible without unreasonable delay. The new RWJF brief explores some of the discrepancies that can arise with varying network adequacy standards and provides examples of how some states have resolved such issues. The brief includes a discussion of essential community providers as defined in the ACA and subsequent guidance and explores their role in assuring network adequacy.

Interested in learning more about network adequacy and essential community providers? Join us at Hill Day, where you’ll have a chance to hear from the Obama Administration’s medical officer at the federal agency tasked with overseeing the ACAs network adequacy requirements. Click here to view the schedule and learn more.

The National Council also encourages readers to view the Coalition for Whole Health’s toolkit on “Ensuring Health Plans Meet ACA Standards for Access to Needed Mental Health and Substance Use Disorder Services.” This document includes a section on network adequacy requirements, including the requirement that provider networks be sufficient to allow access to MH/SUD services without unreasonable delay.