NAIC Places Network Adequacy Determination with the States

Finalized on November 22, 2015 after 18 months of discussion, the National Association of Insurance Commissioners (NAIC) approved an updated version of its Managed Care Plan Network Adequacy Model Act. Renamed the Network Adequacy Model Act, the name has been intentionally broadened to expand the applicability and scope of the Act to all network plans that require or incentivize enrollees to use providers that are managed, owned, under contract with, or employed by an enrollee’s insurer.

Updated for the first time in 10 years, the act establishes the standards for the creation and maintenance of marketplace plan provider networks.

Key Provisions:

Network Adequacy: Section 5

Placing Determination with the States

The Model Act takes the responsibility of determining network adequacy criteria away from insurers and places that duty with state insurance commissioners. Commissioners are to determine adequacy by requiring Marketplace insurers submit access plans for state review.

Access Plans

Insurers must file access plans whenever they propose to sell a new network or if there is a material change to an existing network.

Submitted access plans must describe and detail:

  1. A description of their network and insurer’s procedures for making and authorizing referrals in and out of network
  2. Factors used by insurer in building its network and description of the criteria used to select and tier providers
  3. Methods for assessing healthcare needs of covered persons

State insurance commissioners will then evaluate the submitted access plan to determine the adequacy of the network using reasonable criteria that should include measurable, quantitative standards.

Standards the Act suggests for consideration include:

  1. Provider to covered person ratios by specialty
  2. Geographic accessibility of providers
  3. Waiting times for an appointment
  4. Hours of operation
  5. The ability of the network to meet the needs of covered persons, which may include low-income persons; persons with chronic illness, complex health conditions or physical mental or physical disabilities; persons with limited English proficiency
  6. Health care service delivery system options, such as telemedicine or mobile clinics

Rights to Go Out of Network

The Act requires insurers have a process in place to allow enrollees to go out of network at an in-network benefit level if the plan’s network cannot provider enrollees with access to an appropriate provider without unreasonable travel or delay.

Requirements for Health Carriers & Participating Providers: Section 6

Continuity of Care

The Act includes continuity of care protections for enrollees who are in the middle of an active treatment and have their providers leave or removed from their health plan’s network. (Definition of “active treatment” included in Section 6).

Insurers must develop reasonable procedures to transition covered persons undergoing active course of treatment to a participating provider and shall provide written notice to enrollees that the provider is leaving, along with a list of in-network providers who could meet their needs. Enrollees in active treatment can also request “continuity of care” under which they can continue to see providers who are no longer in their networks at in-network provider cost. Continuity can last for up to 90 days.

Requirements for Participating Facilities with Non-Participating, Facility-Based Providers: Section 7

This section provides protections against “surprise medical bills” or “balance bills” that result when consumers go to an in-network facility for emergency or planned visit, but end up receiving care from an out-of-network provider.  In emergencies, enrollees have to pay only what they would pay for care from in-network providers. If a non-emergency situation with a balance bill of more than $500, consumers have a new mediation option in which they pay for what would the service would be at in-network cost and forward the bill to the insurer for a mediation process that takes place between the insurer and the provider.

Disclosure and Notice Requirements: Section 8

When insurers approve care at in-network facilities in advance, they must notify enrollees that some providers may be out of the enrollees’ network. The facilities also must develop similar written notices to be sent to the patient within 10 days of an appointment or at the time of non-emergency admission. The notice must include an estimate of potential out-of-network provider charges for which they might be responsible for and must indicate that the enrollee can contact the insurer for a list of in-network providers in the facility.

Provider Directories: Section 9

The Model Act requires insurers post online provider directories that are current, accurate and searchable and that are updated at least monthly and make printed directories available upon request. The Act also states that both online and print directories must accommodate individuals with disabilities, and includes several new rules to improve provider directory accuracy standards. These new rules prescribe that Marketplace plans must include the following information

  • Contact information/location, specialty, whether providers are not accepting new patients, and languages spoken other than English
  • Plain language description of the criteria used to select and tier providers
  • Indications of which tier a given provider or facility is in
  • A plain language description of the criteria used in building the network, noting that authorization or referral may be required to access some providers, if applicable
  • Customer service email address and phone number or electronic link that covered persons or general public may use to notify the plan of any inaccuracies
  • Information on providers’ facilities and hospitals
  • A link for information concerning assistance for those with limited English language proficiency

The provider directory section of the Act also states that insurers must periodically audit a reasonable sample of their directories and retain documentation of audits to be made available to regulators upon request.


Giving regulators authority to enforce meaningful network adequacy standards more broadly in their states, the NAIC Model Act builds on the national ACA provisions that were only applicable to marketplace QHPs. Now expanded to include individual and group plans sold outside of the marketplaces, the revised Act creates a solid foundation for enacting standardized state law to ensure network adequacy and significantly improve consumer access to care.

CMS expects states to fully adopt the NAIC Network Adequacy Model Act and will be monitoring their progress, with network adequacy and directory accuracy anticipated to be key focus points of 2016 CMS Marketplace compliance reviews.

Reference: NAIC Health Benefit Plan Network Access And Adequacy Model Act


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