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What is “Network Adequacy/Transparency” and what does it mean for families?

Jan 14, 2015

The National Disability Navigator Resource Collaborative’s (NDNRC) blog covered “network adequacy,” which addresses whether sufficient numbers of providers are part of an insurance plan’s network and accessible to their subscribers.  This is especially important for families of children with special needs who may already be using providers treating their child’s complex needs, so that parents have to make sure these providers are “in network” when choosing a new plan.  The NDNRC also has disability- specific factsheets (see resources) for assistors helping families through this process. 

The NDNRC cited a recent report from the Urban Institute on “network transparency”, that is, how easy it is for families to find provider directories.  Please note that this report didn’t assess if there were enough providers (network adequacy) but looked at directories to see how clear and accessible the directories are for families to use.  The report found that the federal Marketplace listed provider directories with plans, but some state Marketplace websites did not.  Some state Marketplaces referred back to the website of each plan to find providers in network.

The report also emphasized how important it is for families to know the type of plan such as Health Maintenance Organization (HMO), etc.  This is because some plans may require referrals for specialty care while others just require using network providers.  If a family doesn’t get a referral when needed, or uses an out-of-network provider, it could result in higher costs.

Lastly, the report emphasized that the provider directories must be accurate.  For example, even if a provider is listed “in-network” s/he may no longer be taking new patients.  For this reason, it is important for families to find out when a provider network directory was last updated.  In addition, the report recommended the availability of a search function to be able to look for a specific provider by name, rather than just listing alphabetically or by specialty.  The directories should also list where the providers are located geographically so that families can find those nearby.  Lastly, it is important that search features include features such as “languages spoken” in order to serve diverse families.

The Healthcare.gov website, which is the federal Marketplace for choosing plans, now lists providers under each plan so it’s easier for families to pick a plan (see resources).   According to the website, “When comparing plans in the Marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctors is important to you, check to see if they are included before choosing a plan.” 

In a previous blog “How Do Parents Know if their Child’s Providers are in Marketplace Plans?” (http://www.fv-ncfpp.org/blog/how-do-parents-know-if-their-childs-providers-are-marketplace-plans/) it was suggested that if families need help finding out which hospitals and providers are in a plan, parents can call the Marketplace at (800) 318-2596 or find “local help” (see resources.) It is important for families to check whether not just the hospital but also each provider is listed in the network.  Just because a hospital is “in-network” doesn’t mean that all the doctors there participate in the network.  Families should also check directly with the health care providers to make sure they are in-network for the plans they are considering and, if applicable, that they are taking new patients.  (Checking with both the plan and the provider is advisable in case one of them provides erroneous information.)

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Lauren Agoratus

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Lauren Agoratus is the parent of a child with multiple disabilities who serves as the NJ Coordinator for Family Voices. She also serves as the southern coordinator in her state’s Family-to-Family Health Information Center.


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