By Sean Miskell

As more Americans gain coverage through the Affordable Care Act’s (ACA) marketplaces, attention is increasingly turning to the quality of this coverage, especially concerning the adequacy of the provider networks available under these plans. Questions about the scope of networks for plans sold through the Marketplace are important with regard to access to care for consumers as well as for public policy debates about the sources of coverage available to families. For example, before the end of 2017, lawmakers will yet again have to decide whether or not to reauthorize funding for the Children’s Health Insurance Program (CHIP). Without CHIP, many families would have to turn to the Marketplace for coverage, but how would the coverage compare to CHIP? A new Government Accountability Office (GAO) report starts to answer that question for a small handful of states and recently released federal regulations promise consumer-friendly ratings of the network adequacy of Marketplace plans. Nonetheless, questions remain about the extent to which Marketplace plans are sufficient to meet the needs of children.

Comparing Network Adequacy in CHIP and Marketplace Plans

The findings of a recent GAO report raises concerns about whether network adequacy standards for Marketplace plans sufficiently take into account the particular needs of children. The GAO reviewed network adequacy standards for plans available through CHIP as well as Qualified Health Plans (QHPs) available through the Marketplace in five states (AL, MA, PA, TX, WA). The watchdog agency found that these states required QHPs to follow fewer provider-specific standards relative to CHIP requirements. For example, CMS requires QHPs sold through the Marketplace to cover at least one ‘Essential Community Provider’ in a range of categories, none of which are specific to pediatric providers. By contrast, the GAO found that the CHIP plans in the selected states were more likely to have pediatric-specific standards such as provider-to-enrollee ratios, time and distance standards, or requirements regarding capacity and availability.

Interviews the GAO conducted with issuers and hospital representatives raised additional concerns. For example, while nearly all issuers include at least one children’s hospital in their networks, hospital representatives raised concerns that some of these plans incorporate tiered networks and placed children’s hospitals in tiers that require more cost-sharing. Further, both CHIP and QHP issuers told the GAO that they face challenges recruiting and retaining pediatric specialists.

Federal Efforts to Improve Network Adequacy and Increase Transparency

While the recent GAO report is a good first step towards understanding how children would fare under QHPs relative to CHIP plans, its findings are limited to the five states studied and are not generalizable to the country as a whole. However, recently released federal regulations promise to provide more information to consumers about QHP networks. In the final Notice of Benefit and Payment Parameters for 2017, which establishes federal regulations for QHPs sold through the Federally Facilitated Marketplace (FFM), CMS announced plans to provide a measure of the “network breadth” of QHPs. CMS elaborated on this new measure in its final 2017 letter to issuers in the FFM. While the letter to issuers is not federal regulation, but rather serves as guidance to insurance carriers outlining what criteria the feds will use in certifying that plans meet the requirements to be sold through the FFM. In this letter, CMS announced that it will develop a measure called the Provider Participation Rate, which will capture the number of providers in a number of categories in each plan relative to the total number of such providers at the county level and categorize plans as either Broad, Standard, or Basic.

Fortunately for those looking for more information on how well QHP networks serve children, one of the specified Provider Participation Rate categories is pediatric primary care (along with adult primary care and hospitals). But while these measures are a helpful step forward providing more information to consumers about QHP networks, CMS’ methodology ensures that only 16 percent of QHPs can ever be categorized as “Basic.” Further, a recent study of hospital networks in QHPs by McKinsey shows that an increasing proportion of consumers shopping for plans in the Marketplace only have narrow networks to choose form.

Meanwhile, CMS declined to establish a federal default standard set of requirements for network adequacy in for QHPs in the 2017 regulations, instead opting to give states time to incorporate the National Association of Insurance Commissioners (NAIC) model act on network adequacy. But while CMS stopped short of establishing quantitative measures of network adequacy via regulation, the federal government will incorporate maximum time and distance standards in its certification process for QHPs, as outlined in its 2017 letter to QHP issuers in the FFM. However, there are no pediatric-specific measures, and it is not clear what implications these standards will actually have for plan certification, especially since the letter makes clear that regulators at CMS “anticipate that the vast majority of QHPs today would pass these time and distance standards, either numerically or based upon justifications.”

More work to do to ensure that private plans meet children’s needs

Taken together, these developments and reports represent progress in providing information on how children fare under QHPs and CHIP. However, more information is needed, as well as better regulation to ensure that plans provide networks that can meet children’s needs. CMS would be wise to incorporate more measures that intend to capture whether plans meet the needs of children, who often require more specialized care than adults. Further, the federal government should conduct more research of its own comparing how well different sources of coverage meet the needs of children, and they should fully release the results of these studies. Say Ahhh! readers surely remember how long we waited for the Congressionally-mandated report comparing CHIP and QHP coverage, while the GAO report notes that HHS’ Assistant Secretary for Planning and Evaluation (ASPE) has contracted for studies looking at provider networks in CHIP, Medicaid, and QHPs in six urban areas but has not published the results of these studies. More of this kind of information is helpful not only to families navigating sources of coverage but also to provide important insights to policy makers as they make choices about the future of children’s coverage.