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Making Affordable Care Act Coverage a Reality: A National Examination of Provider Network Monitoring Practices by States and Health Plans

Robert Wood Johnson Foundation

Karen Brodsky
Barbara Markham Smith
Diana Rodin

This qualitative study examines the standards and practices that state agencies and health plans use to ensure access to care in the period following the implementation of the Affordable Care Act (ACA). Based on evidence gathered through surveys of and interviews with key informants in state agencies and plans, the study explores the standards applied by commercial insurance regulators and Medicaid agencies and the practices actually employed by Medicaid managed care organizations (MMCOs) and Qualified Health Plans (QHPs) in Marketplaces to form provider networks and monitor performance. While the response sample is small, the information provided paints a picture of the range of standards and practices used and the challenges faced, which provides a basis for identifying gaps in current understanding and strategies and opportunities for developing best practices.