Insurance commissioners across the country are pushing for new rules to force insurers to give their members more options, a response to increasing pressure from consumers unsatisfied with the number of providers offered by plans sold on PPACA insurance marketplaces.

The use of narrow networks varies across the country. One study this summer found that 83 percent of plans offered in Georgia included narrow networks, while in other states, they were nonexistent.

The narrowness of such networks varies dramatically, as well. For instance, a recent study from Harvard found that 15 percent of plans offered on the federal insurance marketplace did not include any doctors for at least one critical specialty, such as psychiatry or arthritis treatment.

The American Academy of Emergency Room Physicians recently complained that narrow networks were forcing more patients into the ER to get basic services that they can’t easily get from primary care physicians or specialists in their networks. Often, the nearest specialist or PCP is too far away.

Consumers are frustrated by the lack of options as well as how confusing it is to determine whether the services they seek are included in their plan. The New York Times reports that many patients have been outraged after getting a larger-than-expected bill from a hospital that was in their network because the doctor who treated them was not in the network.

In response, the National Association of Insurance Commissioners has developed a model law that it recommends states implement to address coverage gaps. The law, the organization states, is aimed at requiring insurers to include enough providers for consumers to get all the services they need “without unreasonable travel or delay.”

The NAIC suggests that state commissioners use a number of criteria to determine whether a plan is too narrow, including the number of doctors included in a geographic area and the number of people in the plan compared to the number of doctors offered.

The model law would also require insurers to regularly update their provider listings so that consumers have up-to-date information on whether the care they are seeking is in-network. California fined two insurers last week for posting inaccurate doctor directories.

Obviously, the insurance industry feels differently about narrow networks, arguing that such plans allow for cost-savings.

Under the commissioners’ proposals, insurers and hospitals would be required to inform patients of any possibility that they may be charged extra by “a health care professional, such as an anesthesiologist, pathologist or radiologist,” who does not participate in the insurer’s network.

In such situations, the proposals say, patients should not be forced to pay more than their usual share of the bill for services provided by doctors affiliated with their health plan. Doctors who object to the amount of the payment could haggle with the insurer in a mediation process, but the patient would be “held harmless.”

Stephanie Mohl, the manager of government relations at the American Heart Association, said the proposals were “a huge step forward” for patients.

In determining whether a network of providers is sufficient, state insurance commissioners would consider factors like the ratio of people enrolled in a health plan to the number of doctors in each specialty, the “geographic accessibility of providers,” waiting times for appointments, and the ability of health plans to meet the needs of low-income people and “children and adults with serious, chronic or complex health conditions or physical or mental disabilities.”

The commissioners developed the proposals in an exhaustive 18-month drafting process that was open at every stage to consumers, insurers, health care providers and other experts.

Instant Insights /

Insurance commissioners call for expanded provider networks

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