Standards for Health Insurance Provider Networks: Examples from the States

When health plans design their provider networks, they need to ensure that these networks are adequate and provide meaningful access to care. The Affordable Care Act established the first-ever federal rights guaranteeing private insurance consumers access to adequate networks. Many states also have laws and/or regulations to help ensure that networks can meet consumers’ needs.

This brief profiles laws, regulations, and guidance in place in states around the country. Rather than offering a 50-state survey of standards, the brief instead highlights good examples of network adequacy protections. These protections can serve as models for other states or for the federal government as they take steps to ensure that all health plan provider networks deliver meaningful access to care.

The brief discusses the following protections:

• accurate information about providers
• timely access to care
• adequate numbers of providers
• adequate types of providers
• inclusion of Essential Community Providers
• adequate geographic distribution of providers
• access to out-of-state providers
• accessible hours
• language-accessible and culturally-competent care
• rights to go out of network
• continuity of care