Washington state’s network adequacy rules, finalized yesterday, attempt to strike a balance between ensuring that consumers have access to care and allowing plans the flexibility to try innovative networks and keep costs down, but they certainly did not please everyone! Health plans have argued that the rules are administratively burdensome and onerous. Providers, including children’s hospitals that care for some of the most vulnerable children, worry that the rules do not support their inclusion in networks and will allow plans to cherry pick consumers and limit children’s access to specialty care. However, when compared to the previous rules, these new network adequacy rules have the potential to be a notable step forward for children and families.

Washington is among the first states to significantly revise its network adequacy standards for private plans since the passage of the Affordable Care Act. Network concerns have received lots of attention as millions of people signed up for marketplace plans during open enrollment. Understanding the concerns that have come up in Washington and where the state landed can help stakeholders in other states prepare for this important discussion.

Increased transparency for people shopping for coverage

When it comes to shopping for health coverage, most people want to know if their providers are in-network. Washington state’s new rules require provider directories to include information needed for consumers to be educated shoppers. Provider directories have to be updated monthly and offered to accommodate people with limited English proficiency or disabilities. Each health plan’s directory has to provide specific information for each provider listed, such as referral requirements and languages and interpreter services. Certain primary care practices (primary care, women’s health, pediatrician, chiropractor) also have to indicate whether the practice is closed to new patients. Collecting this info for their provider directories will give issuers a better sense of who is really open for business and accessible in their networks, and keeping the information updated will help families pick a plan throughout the year.

Washington state’s new rules also require issuers to file geographic maps with provider locations for many types of providers each year. These maps will force plans to think more carefully about the networks and gaps will become more obvious. In addition, when consumers complain about gaps, the insurance department will have a handy reference to better understand the problem or provide assistance.

The prior rules required plans to provide a list of participating providers in their network and the number of people enrolled each month.

Fulfilling the promise of the essential health benefits

The ACA’s essential health benefits requirement means little if a plan’s network does not include providers who can provide the essential health benefits and services. Washington state’s new rules state that issuers must not exclude any category of provider licensed by the state of Washington who provides health care services or care within the scope of their practice for services covered as essential health benefits. Essentially, each network has to include licensed providers to cover all the essential health benefits services and treatment. The state’s prior rules referred to the state’s basic health plan as the source of services covered (which will continue to be the standard for plans other than individual and small group).

Specific standards for certain types of services

Washington state’s new rules also set specific standards for many types of providers to ensure that enrollees have a provider within a reasonable distance from their home; can actually find a provider taking new patients; and can make an appointment within a reasonable timeframe. The new rules require distance standards, minimum ratios of patients to providers, and wait time limits for specific providers. Having a standard for each of these three dimensions of access makes each standard more meaningful—having a provider close by is no use if you can’t get an appointment in a reasonable timeframe, just as getting a quick appointment is less helpful when the provider is far away. The prior rules used general terms like sufficiency of numbers, adequacy of choice, and reasonable proximity that were not numerically defined.

• Distance standards: Plans must show that 80% of the enrollees have providers a specified distance from their home or workplace. The distance varies by type of provider and whether the area is urban or rural. Children’s and consumer advocates in Washington are concerned that the distance standards included for commercial plans are not as strict as Medicaid, and will want to continue to monitor these standards in particular.
• Ratios: The ratio of primary care providers to enrollees in an issuer’s service area must meet or exceed the average ratio for the state for the prior plan year.
• Wait time limits: Enrollees must have access to an appointment with their primary care provider within 10 business days of requesting one (other than preventive care) and within 15 days for a non-urgent specialist visit. Urgent appointments must be available within 48 hours (or 96 if prior authorization is required).

Flexibility for alternative standards

The rules also provide some flexibility to health plans that cannot set up a network that meets these requirements. Issuers can make an alternate access delivery request if they cannot meet the network adequacy standards under specific circumstances, such as plans only serving a county with a limited population, or unable to contract with sufficient providers. The rules set up a process and requirements for doing so that include protections for consumers so that enrollees can access all covered services at no greater cost than if the service was obtained from network providers.

Rules a step forward for children and families

The many stakeholders, including children’s advocates, health plans, and providers, will keep an eye on the balance between access to care and cost as the rules take effect for next year’s plans. While these rules are a work in progress, they are a step forward and could do much to support children’s and families’ access to care.