• Issue Brief
  • January 10, 2014

Ensuring Adequate Marketplace Provider Networks Recommendations

The Children's Hospital Association, Children's Defense Fund, Family Voices, First Focus and Georgetown Center for Children and Families developed an issue brief explaining what's needed to ensure adequate marketplace provider networks for children.

Pediatric-specific network adequacy standards should be developed and monitored to ensure that children enrolled in Qualified Health Plans (QHPs) have access to needed services in a timely way.

  • Pediatric provider networks in the marketplaces should include a full range of primary, specialty, and ancillary pediatric providers, and ensure coordination and continuity of care among all providers.
  • Pediatric-specific network adequacy standards (related to timeliness, quantity and types of providers, and monitoring), should be developed with input from pediatric health researchers and providers, and families in order to ensure that children have access to needed services without unreasonable delay. 
  • Pediatric provider networks must be continually assessed to identify gaps in access to care, accompanied by a plan to remedy those gaps and monitor access to care in those areas. 
Network adequacy standards and assessments should assure access for children with special health care needs or limited English proficiency.

  • Pediatric provider network standards for QHPs should specifically reflect the challenges that especially vulnerable populations, such as children with special health care needs, including those with complex conditions, or limited English proficiency, face in securing the care they need when they need it. 
  • Network adequacy standards must require an appropriate distribution of pediatric specialists. Limited or tiered networks that create barriers to appropriate care or substantial disruptions of care and provider relationships can be catastrophic to the development and health of children with special health care needs.
  • Provider networks must include providers who offer services in the appropriate languages to serve the population. Children’s health could suffer if parents are unable to find linguistically and culturally appropriate providers for their families.
QHPs should provide easy access to essential community providers that care for children.

  • States—through both insurance regulation and marketplace policy—should ensure that QHPs have an adequate network of essential community providers (ECPs).   QHPs must be required to contract with, and provide adequate payment to, all pediatric ECPs including, but not limited to, children’s hospitals and school-based health centers. A robust pediatric ECP network will assure access to these especially qualified providers with expertise in the care of low-income and critically or chronically ill and disabled children. 
  • Pediatric ECPs are uniquely positioned to provide critically important support services that address the health care access barriers these children face, including language services, social service interventions, and outreach. Adequate reimbursement for these services must be assured as well. 
Children, particularly those with chronic and complex conditions, must have access to out-of-network providers at no additional cost if no network provider is accessible for needed services in a timely manner. 

  • Children must be able to access the pediatric specialty care they need even when the QHP network has an insufficient number or type of provider to provide the needed care. Children with complex or chronic conditions may need specialty care from a type of provider not in a QHP network, given the shortage of certain types of pediatric specialists nationwide, and the possibility of narrow provider networks in some plans. 
  • Children must be able to access those providers at no additional cost and do so in a timely manner when it is determined that the care is appropriate.
  • QHP policies and rules for accessing out-of-network care and the process for appeals of denials of requests for out-of-network care must be made clear to consumers. 
Provider networks that overlap with Medicaid/CHIP can help promote continuity of care for children who move between the Exchange and public coverage.

  • Inevitably, some children will move between marketplace and Medicaid/CHIP coverage as their family income or other characteristics change.   States should establish network standards that require or encourage aligned or overlapping pediatric provider networks with Medicaid/CHIP to allow for continuity of care for children who move between public and private coverage.   
Dental provider networks for children must be assessed and any deficiencies addressed.

  • Dental provider networks must be adequate to assure that oral health services will be accessible to children without unreasonable delay. 
  • All dental provider networks must be assessed, including those in the stand-alone dental plans that are offered in the marketplaces, as rigorously as medical care provider networks for children. 
  • Marketplaces should have an initial standard for dental provider network adequacy and have a system to monitor access to dental care for children. At a minimum, dental plans should be required to demonstrate the standards and procedures they have to maintain a network that is sufficient in the number and types of providers to assure timely access to oral health services for children.
  • States should continue to study the issue of meaningful dental network adequacy standards specific to their localized conditions.  
Network adequacy standards and assessments should be transparent. 

  • The state’s network adequacy standards, assessment procedures, and data documenting QHP compliance with those standards, should be clear and transparent to the public.
  • Assessment results and data on QHP network adequacy (e.g., wait times, numbers, and types of providers) for children should be publicly disclosed, as well as health plan accreditation status and Consumer Assessment of Health Care Providers and Systems survey results for children, including the child access to care survey and the survey for children with chronic conditions. 
  • QHPs should be required to report publicly on the impact of their provider networks on children’s access to care.

Additional background information on network adequacy can be found in the attached handout.

Association Contact: Jan Kaplan, (202) 753-5384