When networks are limited, consumers are forced to wait or travel long distances for care, pay higher costs for treatment from a non-network provider, or forgo care altogether.
Network gaps for mental health (MH) and substance use disorder (SUD) providers are particularly problematic. Consumers with private health plans access MH and SUD services from out-of-network providers at a significantly higher rate than for other medical services. Network utilization disparities have persisted even though the Mental Health Parity and Addiction Equity Act (Parity Act) prohibits such discrimination.
The report describes the federal and state regulatory framework for defining and monitoring network adequacy for public and private health plans, and offers recommendations to improve and enforce network adequacy standards. Also included is a 50-state survey of quantitative metrics adopted for state-regulated private health plans and offers a “parity assessment” of those state MH and SUD provider metrics.
- Medicaid managed care plans, Affordable Care Act qualified health plans (QHPs) and Medicare Advantage plans are required to establish adequate provider networks. Federal rules for Medicaid managed care plans and QHPs defer to state regulatory standards, while Medicare Advantage establishes quantitative metrics for providers, including MH providers.
- Twenty-nine (29) states have adopted at least one quantitative metric to define network adequacy for state-regulated private insurance plans – most frequently, geographical distance standards. Only 7 states have adopted quantitative standards for the three most common metrics: geographical distance, appointment wait time and provider-enrollee ratios.
- Sixteen (16) states have adopted at least one quantitative metric for MH and SUD providers, but only 2 states have adopted all three metrics. Based on the numerical metrics alone, the standards for MH and SUD providers are comparable to or more generous than standards for medical providers.
Multiple strategies are needed to create robust networks and protect consumers who cannot find a network MH or SUD provider for covered services. At a high level, recommendations include:
- Adoption of parity-compliant quantitative standards for a wide range of MH and SUD providers in both public and private insurance
- Improved regulatory oversight of health plan compliance and greater transparency of plan compliance
- Better consumer education