Private Health Insurance: State and Federal Oversight of Provider … – Government Accountability Office
A majority of Americans are covered by private health insurance plans. Health plans set up provider networks—contracted doctors, other providers, and facilities—to provide medical care to enrollees.
A provider network is considered “inadequate” if it doesn’t have enough providers for enrollees to receive timely care nearby. Inadequate networks may lead enrollees to seek higher-cost care from out-of-network providers.
Most states said they review plans for adequacy prior to approving them for sale and on an annual basis. But the standards used to assess network adequacy—like maximum wait time or sufficient choice of providers—varied by state.
Provider network adequacy refers to a health plan’s ability to deliver the benefits promised to enrollees by providing reasonable access to a sufficient number of in-network providers. Inadequate networks can make it more likely that enrollees obtain care from out-of-network providers, which can be more expensive. State agencies and the Departments of Health and Human Services and Labor (DOL) each have responsibilities for overseeing private health plans, including, in some cases, certain requirements related to the adequacy of provider networks. These oversight practices varied.
While there is no comprehensive information on the overall adequacy of provider networks, states and CMS identified issuers that were not in compliance with network adequacy standards. Information also indicated other potential limitations in access to certain provider specialties like mental health and pediatrics. States and stakeholders also reported interrelated factors that may contribute to inadequate networks—provider shortages, challenges in contracting with providers, and geography. These interrelated factors were consistent with the literature. For example, provider shortages can contribute to inadequate networks. This can be particularly challenging in rural areas because such shortages limit the number of available providers with which an issuer can contract.
The majority of Americans—or about two-thirds of individuals in the United States—receive their health coverage through private health plans. Health plans establish provider networks—the doctors, other providers, and facilities with which a plan contracts—to provide medical care to their enrollees. A provider network can be inadequate if the network has an insufficient number of providers or facilities to provide care to health plan enrollees. Inadequate networks can affect enrollees’ ability to access care in a reasonably timely manner.
The Consolidated Appropriations Act, 2021, includes a provision for GAO to review the adequacy of provider networks in individual and group health plans. This report describes (1) state, CMS, and DOL oversight of the adequacy of provider networks; and (2) what is known about the adequacy of individual and group health plans’ provider networks.
For this report, GAO (1) reviewed CMS and DOL guidance and reports; (2) conducted a survey and received responses from 49 states and the District of Columbia about oversight practices and any issues states experienced with network adequacy; (3) interviewed officials from CMS, DOL, selected states, and stakeholders, such as the American Medical Association; and (4) reviewed available literature that assessed provider network adequacy.
GAO provided a draft of this report to the Department of Health and Human Services and DOL. Both agencies provided technical comments, which were incorporated as appropriate.
For more information, contact John E. Dicken at (202) 512-7114 or [email protected].
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