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Health Plan Scrutiny
Network adequacy
Network adequacy is defined by the
National Conference of State Legislatures as
"a health plan's ability to deliver the benefits
promised by providing reasonable access to
a sufficient number of in-network primary
care and specialty physicians, as well as
all healthcare services included under the
terms of the contract."
The federal government has crafted adequa-
cy rules for Medicare Advantage and Obam-
acare plans. The regulations now taking effect
in Connecticut are similar in many ways.
Under previous Connecticut law, insurers
were required to attest they were accredited
by one of two accrediting entities that moni-
tor network adequacy, but the state played no
role in that oversight.
Doctors weren't satisfied with that being
the sole requirement, as accreditation involves
more than just network adequacy. If a health
plan failed the adequacy standards but did well
in other areas, it would still pass, Katz said.
Wade said the accreditors — National
Committee for Quality Assurance and URAC
— have robust and regularly updated stan-
dards, but the new rules allow the state to
check their work and make its own decision.
A spokesman for the Connecticut Asso-
ciation of Health Plans did not respond to
requests for comment.
The law gives Wade wide latitude in how
she reviews networks. There is no specif-
ic formula she's mandated to use, but her
review could include such metrics as pro-
vider-patient ratios, geographic availability
and wait times.
Doctors have pushed for specific metrics
to be applied and Katz said his organization
intends to pursue further legislation to make
that happen.
Asked if she would be in favor of stricter
rules, Wade said she would need to see a spe-
cific proposal first.
"The law just went on the books, so we need
to give it a little bit of time to work," she said, add-
ing that her office will listen to any complaints.
Gordon, the oncologist, said he hopes the
new rules lead to noticeable improvements in
the year ahead.
He said he has increasingly had trouble
referring patients to other in-network doc-
tors. Some might be far away, while others
may not have openings for several weeks or
more. That, to him, is inadequate.
Insurer directories can also come into
play when referring patients. Since Gordon's
staff uses them to help determine where to
send patients, inaccuracies can cause delays
and other issues, he said. n
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