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How States Are Improving Consumers’ Access to In-Network Health Care Providers

By Claire McAndrew,


Updated May 5, 2016

In 2016, there has been tremendous progress in improving consumers’ access to in-network providers. At Families USA, we have launched a campaign to enact standards to address this issue at the state and federal level. The campaign focuses on the three strategies that are most important to ensuring that consumers can see the providers they need through their health plans:

  • Improving network adequacy: making sure that consumers can get the right care, at the right time through their health plan networks, without having to travel too far
  • Improving provider directories: ensuring that health plans provide accurate information about which providers and facilities are in their networks
  • Protecting consumers from surprise medical bills, which can add up to thousands of dollars for out-of-network services that people get at in-networkfacilities

Our campaign supports the work of advocates in many states, including close partnerships with advocates in Georgia, Maryland, and Colorado.

In this blog, we discuss how Georgia, Maryland, and Colorado are making progress on implementing standards for network adequacy and provider directories to improve consumers’ access to providers in the private insurance market. The recent victories in these states—and the tactics advocates used to achieve them—are examples of what other states can to do to improve network adequacy and provider directories.

How the NAIC Network Adequacy Model Act can help states improve access to in-network providers

The Network Adequacy Model Act, which the National Association of Insurance Commissioners (NAIC) adopted in late 2015, has created an important foundation for states in their work to improve network adequacy and provider directories. State legislators are finding its language useful, since they know it was crafted through an intensive stakeholder input process and unanimously adopted by all members of the NAIC, who represent every state and both political parties.

The Network Adequacy Model Act has spurred action by state decision makers on both sides of the aisle to move the ball forward in key areas of provider access reforms.

Georgia’s bill to require health insurers to maintain accurate provider directories

Advocates at Georgians for a Healthy Future (GHF) had heard concerns about provider access in their state. They wanted to ensure that consumers from all walks of life could get access to in-network providers and believed that this issue would resonate with a range of state legislators.

In the fall of 2015, the state senate appointed Cindy Zeldin, the executive director of GHF, to a study committee charged with examining network adequacy and provider directories. Families USA helped GHF develop a campaign to turn a study committee into enacted legislation.

“Families USA shared the same goals on this issue and had the expertise and resources that we could leverage to make a meaningful impact in our state’s policy environment. No matter the hour of day (or night), Families USA was poised to answer questions about policy nuances, review documents, or fly to Atlanta to testify before a legislative committee. There is no doubt that the success of SB 302 is in part attributed to the success of the partnership we have with Families USA.” – Meredith Gonsahn, Health Policy Analyst, Georgians for a Healthy Future

Five months of legislator education, policy deliberation, and intensive strategic thinking ensued. To inform this process, GHF held a policy forum in February to release legislative recommendations on network adequacy and provider directories, and it conducted a secret shopper survey. GHF walked away with a strong bill, SB 302, which requires insurers to maintain accurate provider directories. It passed the House and the Senate with overwhelming support.

As described by Cindy Zeldin, “SB 302 garnered widespread support from policymakers who understand how important it is for consumers to have accurate and usable information about their health care choices. The legislative process was collaborative and constructive, and we are optimistic that the Governor will sign this important consumer protection bill into law.”

The governor signed the bill into law on April 26, 2016!

The bill includes many provisions that are in the NAIC Network Adequacy Model Act and in Families USA’s recommendations for improving provider directories. These include, but are not limited to, requirements that:

  • Insurers must allow the public to report directory inaccuracies by phone and an email address or web link. Insurers must investigate these reports and verify the accuracy of directory information or modify it accordingly within 30 days.
  • Insurers must review and update their entire directories by January 1, 2017. Every year after that, they must audit a reasonable sample of their directories and make any needed corrections.
  • Insurers must contact any providers listed in their directories that have not submitted claims within the past 12 months or otherwise communicated that they still intend to be in the insurer’s network. If insurers cannot reach providers within 30 days, they must remove those providers from their directories.
  • People must be protected from excess out-of-pocket costs when they rely on information in directories that is materially inaccurate and subsequently receive care from out-of-network providers that they believed were in-network.
  • Insurers must provide information regarding tiered networks: Tier assignments must be clear for each provider and facility, and insurers must provide a description of the criteria they use to create tiers.

Stakeholders in Maryland come together to address network adequacy and provider directories

Adrienne Ellis from the Mental Health Association of Maryland and Leni Preston from the Maryland Women’s Coalition for Health Reform entered the 2016 legislative session with the goal of improving health care consumers’ access to providers.

Adrienne and Leni both wrote reports last year based on secret shopper studies. These reports documented the problems Marylanders face when trying to obtain care and with getting accurate directory information from their health plans. The compelling data in the reports, combined with the NAIC’s Network Adequacy Model Act, made a strong case for passing legislation that would improve access to providers.

To get the process moving, a stakeholder workgroup met regularly throughout the summer of 2015 to discuss ways to address these issues under the guidance of the Maryland Health Benefit Exchange (the agency that runs the state’s health insurance marketplace). Maryland advocates then worked with Families USA to develop a campaign designed to highlight the need for Maryland to catch up to other states in terms of consumer protections for provider access. The campaign also highlighted how the state will benefit from protections such as those in the NAIC model act. Collectively, these efforts resulted in SB929/HB1318, Network Access Standards and Provider Network Directories.

The bills contain many provisions that will improve network adequacy and provider directories for Marylanders, including but not limited to requirements that:

  • The insurance commissioner must adopt regulations by December 31, 2017, that include criteria to ensure that health plan networks are sufficient. These must include quantitative criteria, such as metrics to ensure that providers are geographically accessible, appointment wait time standards, and provider-to-enrollee ratios.
  • Insurers must provide a customer service phone number, a link to an email address, or another electronic way for plan enrollees and prospective enrollees to report inaccuracies in provider directories. Insurers must investigate these reports and take corrective action, if necessary, within 45 days of receiving them.
  • Insurers must:
    • Periodically review at least a reasonable sample of their directories for accuracy.
    • Keep documentation of these reviews.
    • Make the reviews available to the insurance commissioner upon request.
    • Alternatively, insurers may contact providers listed in their directories who have not submitted claims in the last six months to determine if the providers intend to remain in the insurer’s network.

Many Maryland provider and consumer groups support the bills. The Mental Health Association of Maryland, the Maryland Women’s Coalition for Health Reform, and Families USA testified together on the sponsor’s panel during the bill hearing in the House and on a panel in the Senate hearing.

The bills faced initial challenges, including a lack of support from insurers. However, legislative leadership and the willingness of all parties to come to the table and negotiate resulted in bills that passed their respective chambers by unanimous votes. After some technical changes, the Senate version of the bill received another unanimous vote and is now headed to the governor’s desk. All stakeholders look forward to the governor’s signature. Governor Hogan signed the bill on April 26, 2016!

Colorado Division of Insurance works with stakeholders to shape standards for provider directories and network adequacy

In Colorado, the Division of Insurance (the Division) is using its authority to issue guidance in the form of bulletins to enact important new consumer protections regarding network adequacy and provider directories. The Division has established a stakeholder input process to guide its thinking, and advocates from the Colorado Consumer Health Initiative (CCHI) have been involved every step of the way.

Families USA is providing in-depth technical assistance to CCHI in its work to analyze the Division’s proposals and to assess best practices in provider directory and network adequacy standards around the country. CCHI is providing comments to the Division on how to design these standards to best help health care consumers.

The Division has finalized its bulletin on network adequacy standards, which includes standards for appointment wait times, travel distance, and provider-to-enrollee ratios by specialty (primary care, pediatrics, OB/GYN, etc.) or service type (emergency, preventive visit, urgent care, etc.). It will soon finalize its bulletin on provider directory standards. The Division also plans to produce a bulletin on continuity of care for consumers whose health care providers are terminated from their plan’s network mid-year.

The Division intends to include the policies these bulletins address in regulations that it will release by the end of the year.

State advocates, Families USA, and policymakers continue building momentum to improve access to providers

Once people get health insurance, it is critical that they be able to get care from appropriate providers in a timely manner, without traveling too far. There is significant momentum among state policymakers to improve consumers’ access to providers, and, due much in part to advocates’ work, this momentum is likely to grow. We will continue to provide updates on efforts by Families USA, our state advocacy partners, and policymakers nationwide to improve standards for network adequacy, provider directories, and other important provider access issues.