Insurance Regulators Adopt New Network Adequacy Model Act
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On November 22, 2015, the National Association of Insurance Commissioners (NAIC) adopted revisions to the Managed Care Plan Network Adequacy Model Act. Adoption of the revised Model Act comes after nearly a year of public engagement and feedback from stakeholder entities, including UCAOA.

The Model Act, which was last updated nearly two decades ago, is intended for use by state legislatures and regulators. States have the discretion to choose which parts, if any, of the Model Act to adopt. Revisions to the Model Act came amidst growing frustration among consumers about health plans with inadequate provider networks and provider directories that are either outdated or lack details to make informed decisions.

The Model Act establishes standards for the creation and maintenance of health plan networks and assures the adequacy, accessibility, transparency and quality of healthcare services offered under a network plan, including by requiring health carriers to maintain and follow access plans that consist of policies and procedures for assuring the ongoing sufficiency of provider networks. At UCAOA’s urging, the new Model Act requires a health carrier, as part of its access plan, to provide to state regulators its method for informing covered persons of the plan’s procedures for covering and approving urgent care. While UCAOA pushed for inclusion of a definition of urgent care in the Model Act, regulators decided to defer to the states.

The Model Act has a number of positive improvements, including new provider directory requirements and transparency requirements for network design and provider selection. However, several new provisions in the model have raised concerns from key provider stakeholders, including the American Medical Association (AMA). Namely, the AMA is concerned that language meant to recognize the growth of telemedicine may be interpreted by legislatures to allow telemedicine providers to wholly replace in-person providers for the purposes of meeting the state’s network requirements. The AMA also believes that when considering adoption of the Model Act, states should determine whether networks are adequate before health plans can be sold to consumers.

UCAOA will closely monitor state legislative and regulatory activities in this area and will advocate for definitions of urgent care centers that distinguish them from retail and other alternative acute-care sites of service.

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