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INS-058: Network Adequacy and Transparency

Network Adequacy and Transparency: The Wisconsin Medical Society supports the following statements regarding insurance networks.

  • Narrow networks should not be designed solely on the basis of cost or constructed in such way that places need specialty care services, providers or medications in the highest tiers, which can cause consumers to suffer a large financial burden and may delay the purchase of needed drugs and care.
  • Insurers must be unequivocally transparent in provider selection standards. Consumers, providers and regulators should be made aware of the basic methods that were used to create the network, which may be centered on lower-cost providers.
  • The state government, federal government or regulating exchange entity should have the ability to ensure that:
    1. Provider networks include a full range of primary, specialty and subspecialty providers for children and adults.
    2. Health plans have an adequate number of primary care physicians (PCPs) who are willing to accept new patients.
    3. Health plans have an adequate number of PCPs and specialists with admitting privileges at network hospitals.
    4. Insurers should have or should make arrangements for coverage of out-of-network care at in-network costs for members when in-network provider access is insufficient.
  • Quantitative measurements should be used to evaluate network adequacy that allow state regulators to adapt specific thresholds that are reasonable for Wisconsin. Among the quantitative measures that should be included are:
    1. Maximum travel time and distance, with appropriate adjustments for geographic differences and for the regionalization of specialty care to ensure access to all covered services.
    2. Appointment wait times.
    3. Willingness to admit new patients.
    4. Provider hours and availability.
    5. Availability of technological, diagnostic, and ancillary services.
  • When out-of-network care is received because there is no provider in-network capable of providing a covered service, cost-sharing and other plan requirements for the consumer should be the same as if the provider was contracted and in-network. In addition, the insurer must take immediate steps to remedy the gaps in the network. If the insurer has arranged for access to that specialized care outside the geographic region, the regulator should still consider approval of the network.
  • Network adequacy standards should apply to the lowest cost-sharing tier of any tiered network. The use of tiered provider networks and formularies must be regulated to ensure that consumers of all ages have access to all covered services, including specialty services, without additional cost sharing or administrative burdens.
  • Tiered networks must not be designed solely on the basis of cost and must not impede the provision of timely and high quality care. (HOD, 0416)