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Report Examines Provider Network Monitoring Practices

HMA released findings from a qualitative study this week in the report, “Making Affordable Care Act Coverage a Reality: A National Examination of Provider Network Monitoring Practices by States and Health Plans.”

The study examined the standards and practices that state agencies and health plans use to ensure access to care in the period following implementation of the Affordable Care Act (ACA). The report was prepared by HMA’s Karen Brodsky, Diana Rodin, and Barbara Smith with support from the State Health Reform Assistance Network, a Robert Wood Johnson Foundation program.

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. Among the report’s key findings:

  • Network standards differ significantly between state insurance regulators and Medicaid agencies
  • Health plans report they are exceeding states’ network standards
  • Few states track provider network overlap across plans.