This United Hospital Fund (UHF) report, supported by NYHealth, examines public and private health insurance plans’ provider networks and current State standards and processes for determining the adequacy of these networks.
For plans that provide both private commercial coverage, such as HMO products, and public insurance coverage, such as Medicaid, strong alignment between their provider networks will be important as the New York Health Benefit Exchange readies itself to implement health reform. Strong alignment among provider networks will enable seamless transitions, continuity of care, and the ability for enrollees to keep the same doctor as their income and eligibility status changes.
Among the findings and recommendations:
- Plans in upstate regions of New York have significant overlap in their provider networks for their private and public insurance plans, ensuring high continuity of care.
- Two carriers—HealthFirst and Fidelis—have provider networks that far exceed the minimum standards for their Medicaid managed care plans.
- Various consumer protection laws related to network adequacy are in place already, but policymakers may want to take the opportunity to strengthen standards to ensure uniformity across all markets and network-based products.
- Opportunities exist to upgrade and streamline New York’s current data collection system in order to make it a more useful tool for network determinations and to better inform and engage health care consumers.
- The Exchange can help ensure its long-term sustainability by offering an extensive range of health insurance products and networks.
This report is the sixth in a series of reports focused on New York’s Exchange. The first report examined the initial set of governance and organizational choices for states in designing their exchanges. The second report examined the initial set of governance and organizational choices for states in designing their exchanges. The third report focused on two discretionary decisions for New York involving the Exchange: merging the exchanges for individuals and small businesses and merging the individual and small group markets. The fourth report explored the roles the Exchange should play, ranging from a passive market organizer model to an active purchaser. The fifth report examined the various plan options that will serve as a benchmark plan for implementing the essential health benefits rule required for all individual and small group policies.