Key Implementation Issues: Network Adequacy

According to the Congressional Budget Office, 14 million individuals will be newly eligible for health insurance through Medicaid, CHIP, or the marketplaces in 2014. The entry of millions of newly insured individuals will certainly strain the capacity of an already burdened health provider workforce. Estimates from the American Association of Medical Colleges suggest that by 2015, there will be a shortage of nearly 30,000 primary care providers, including pediatricians. Some challenges and considerations for states related to provider network adequacy include:

  • Ensuring participation of providers in Medicaid and CHIP: While CHIP and Medicaid have built strong pediatric provider networks, low provider reimbursement rates have consistently been cited as a factor deterring providers from engaging with public programs, particularly Medicaid. To attract providers to participate in Medicaid, the ACA established a temporary Medicaid primary care rate increase effective January 1, 2013, for a period of two years. However, states that reduced their provider rates as of July 1, 2009, will need to restore their rates to their 2009 levels to be eligible to receive federal funding.
  • Ensuring adequate pediatric provider networks in the marketplace: The ACA requires that qualified health plan (QHP) issuers maintain provider networks that are “sufficient in number and type of providers” and include essential community providers (ECPs). ECPs, including Federally Qualified Health Centers, family planning providers, and school-based health centers, serve substantial proportions of children and youth in many communities. The ACA and an April 2013 letter to issuers from the Centers for Medicare and Medicaid Services give states and plans flexibility in choosing ECPs to meet the minimum requirements for QHP certification. States have the opportunity to consider provider network decisions carefully and create networks that maintain and enhance access to care for children and youth.
  • Alleviating disruptions in care by aligning providers or plans across insurance affordability programs. States could do this by requiring or incentivizing a QHP issuer to contract with some or all providers or plans participating in Medicaid and CHIP, including child-specific providers that could be considered essential community providers. States could also permit Medicaid and CHIP children, particularly children with special health care needs, transitioning to QHPs to temporarily receive care from non-network providers.
    • New York: During the time that New York’s Medicaid and Family Health Plus enrollees were transitioning to managed care, they were allowed to continue to receive services from their existing non-participating provider for 60 days from the time of enrollment.

Additional State Resources

  • California: This California Health Benefit Exchange board meeting presentation outlines options and final recommendations for qualified health plan strategies, including provider network access.
  • Maryland:The Maryland Health Benefit Exchange’s Access to Care Program plans to closely monitor access to care, including engagement with essential community providers, and network adequacy.

NASHP Resources

Access and the Safety Net: This NASHP web page features a series of publications related to potential roles and policy options for the safety net to support continuity of care across programs and meet the health care needs of vulnerable populations through health reform implementation.

Other Resources

Comments on Federally-Facilitated Exchanges: Children’s advocates outline their concerns regarding essential community providers in a letter to the Centers for Medicare and Medicaid Services.

Will There Be Enough Providers to Meet the Need? Provider Capacity and the ACA: This Urban Institute report highlights states’ strategies for increasing provider reimbursement and expanding the capacity of the primary care workforce.