A majority of People are lined by non-public medical health insurance plans. Well being plans arrange supplier networks—contracted docs, different suppliers, and services—to supply medical care to enrollees.

A supplier community is taken into account “insufficient” if it does not have sufficient suppliers for enrollees to obtain well timed care close by. Insufficient networks could lead enrollees to hunt higher-cost care from out-of-network suppliers.

Most states mentioned they assessment plans for adequacy previous to approving them on the market and on an annual foundation. However the requirements used to evaluate community adequacy—like most wait time or enough alternative of suppliers—diverse by state.

What GAO Discovered

Supplier community adequacy refers to a well being plan’s potential to ship the advantages promised to enrollees by offering affordable entry to a enough variety of in-network suppliers. Insufficient networks could make it extra seemingly that enrollees get hold of care from out-of-network suppliers, which could be dearer. State businesses and the Departments of Well being and Human Providers and Labor (DOL) every have accountability for overseeing non-public well being plans, together with, in some instances, sure necessities associated to the adequacy of community suppliers. These oversight practices diverse.

• Officers from 45 of the 50 states (together with the District of Columbia) that responded to GAO’s survey reported they took various actions to supervise the adequacy of particular person and group well being plans’ supplier networks. For instance, officers from 32 states reported they reviewed well being plans’ supplier networks previous to approval of the plan on the market, and officers from 23 states reviewed plans when there have been adjustments to the community. Officers from 44 states reported in GAO’s survey that they used at the very least one normal to evaluate the adequacy of networks. Examples of requirements embody a most time or distance to a supplier or a most wait time to see a supplier.
• The Facilities for Medicare & Medicaid Providers (CMS) inside the Division of Well being and Human Providers oversees the adequacy of supplier networks for probably the most certified well being plans (QHP) supplied on the federally facilitated exchanges. CMS’s oversight actions embody annual and focused critiques of QHP networks along with critiques of supplier directories—listings of a plan’s in-network suppliers and services. For instance, as a part of the company’s annual assessment of QHPs for plan yr 2023, CMS officers advised GAO they evaluate issuer information on their supplier networks in opposition to CMS’s community adequacy requirements.
• DOL doesn’t have authority or requirements to implement community adequacy for personal employer-sponsored group well being plans typically, however DOL conducts critiques of compliance with psychological well being and substance use dysfunction parity necessities. The DOL enforces these necessities by conducting critiques to make sure that limitations on psychological well being and substance use dysfunction advantages aren’t any extra restrictive than limitations on medical/surgical advantages.

Whereas there isn’t a complete data on the general adequacy of supplier networks, states and CMS recognized issuers that weren’t in compliance with community adequacy requirements. Info additionally signifies different potential limitations in entry to sure supplier specialties corresponding to psychological well being and pediatrics. States and stakeholders additionally reported interrelated components that will contribute to insufficient networks—supplier shortages, challenges in contracting with suppliers, and geography. These interrelated components have been in step with the literature. For instance, supplier shortages can contribute to insufficient networks. This may be notably difficult in rural areas as a result of such shortages restrict the variety of accessible suppliers with which an issuer can contract.

Why GAO Did This Research

The vast majority of People—or about two-thirds of people in america—obtain their well being protection by non-public well being plans. Well being plans set up supplier networks—the docs, different suppliers, and services with which a plan contracts—to supply medical care to their enrollees. A supplier community could be insufficient if the community has an inadequate variety of suppliers or services to supply care to well being plan enrollees. Insufficient networks can have an effect on enrollees’ potential to entry care in a fairly well timed method.

The Consolidated Appropriations Act, 2021, features a provision for GAO to assessment the adequacy of supplier networks in particular person and group well being plans. This report describes (1) state, CMS, and DOL oversight of the adequacy of supplier networks; and (2) what is thought concerning the adequacy of particular person and group well being plans’ supplier networks.

For this report, GAO (1) reviewed CMS and DOL steering and stories; (2) carried out a survey and acquired responses from 49 states and the District of Columbia about oversight practices and any points states skilled with community adequacy; (3) interviewed officers from CMS, DOL, chosen states, and stakeholders, such because the American Medical Affiliation; and (4) reviewed accessible literature that assessed supplier community adequacy.

GAO supplied a draft of this report back to the Division of Well being and Human Providers and DOL. Each businesses supplied technical feedback, which have been included as applicable.

For extra data, contact John E. Dicken at (202) 512-7114 or [email protected].