Ensuring that coverage translates into access to care requires attention to the adequacy of provider networks. States will need to ensure that standards meet federal requirements, and may want to tailor standards to meet state specific needs.
*Full name: Adopt provider network standards for plans in the Exchange that meet or exceed those required by federal laws and regulations.
*Relevance to the ACA:
The ACA establishes minimum criteria for qualified health plans sold on an Exchange; these criteria include provider network standards. Relevant sections include:
§1311 - Qualified health plans must meet these minimum provider network standards:
-- ensure a sufficient choice of providers.
-- comply with rules limiting the re-entry of an insurer in geographic areas in which that insurer has previously denied coverage to new applicants because its provider network would be unable to adequately provide services.
-- provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers.
-- include within plan networks available non-profit and federally funded clinics and hospitals that serve low-income, medically-underserved individuals.
-- be accredited with respect to network adequacy and access by a recognized accreditation entity of health insurance issuers or plans, or receive such accreditation within a period established by an Exchange.less