A network adequacy report MHAMD released in January 2015 sparked a firestorm of debate early in the legislative session. The finding that only 14% of the 1,154 psychiatrists listed on the Maryland Health Benefit Exchange (MHBE) Qualified Health Plan networks were accepting new patients within 45 days was widely quoted by advocates, the press and policymakers. Our study showed that in 2014, the qualified health plans have inadequate networks of psychiatrists to meet the demands of their insured members.
In this blog series, we will explore the policy topic of network adequacy: what it means, its importance for consumers, and what consumer advocates are doing to address the issue. Be sure to subscribe to MHAMD Perspectives in order to receive notification when new posts on this and other topics are available.
What is Network Adequacy?
Anyone who has had difficulty finding a doctor or specialist in their insurance network, had to travel further than they would have liked, or had to wait weeks for an appointment with an in-network provider intimately understands what network inadequacy is. The National Association of Insurance Commissioners (the group of state insurance regulators) defines network adequacy as, “a health plan’s ability to meet the medical needs of its enrollees by providing reasonable access to a sufficient number of in-network primary and specialty care physicians, as well as all other healthcare services for which benefits are included under the terms of the insurance contract.” Essentially, insurance plans must have enough contracted doctors and healthcare providers to provide adequate access to healthcare for their members. Whether or not a network is adequate depends on the definition of “reasonable access” to care. Many states have moved to define, “reasonable” using acceptable wait time and travel distances that can be expected for an in-network appointment.
Why Does Network Adequacy Matter?
When an individual or their employer pays a premium for health insurance, they enter into a contract with the insurance company- entitling them to reasonable access to medically necessary healthcare. In order to provide this access to care, insurance companies must contract with enough providers, including specialists to meet the needs of all of their members. When there aren’t enough providers in a network, consumers experience difficulties in securing appointments, delays in access to necessary care, or much larger out of pocket costs for healthcare services. Often, especially in regards to mental health care, consumers are forced to see out of network providers, who don’t participate with private health insurance. These providers charge the consumer a market-based price for a visit, and then the consumer is responsible for getting reimbursement from their insurance company, which is often much less than the cost of the appointment. For example, an individual could pay $200 for a 60 minute psychotherapy visit with a psychiatrist, but receive as little as $50 in reimbursement from their insurance company. These out of pocket costs add up quickly- forcing consumers to make difficult choices about their healthcare.
What Can You Do?
Maryland law entitles consumers to “access to primary and specialty care without unreasonable delay or travel.” If you are having difficulty getting an appointment with an in-network mental health provider, there are steps you can take before you resign yourself to going out of network for care. Ask your insurance company to give you the contact information for a few providers who are accepting new patients and available for appointments in the next few weeks. If they are unable to do this, you can request that they provide a special case agreement, allowing you to visit an out of network provider, but at in-network cost, which could save you hundreds of dollars.
Please contact Adrienne Ellis, Director Healthcare Reform and Community Engagement at aellis@mhamd.org if you are experiencing difficulty in finding an appointment with an in-network provider and need assistance. If you have any questions about this post or want to share your story, we want to hear from you.
In the next installment- What are State and Federal Regulators Doing to Insure Network Adequacy?