For Consumers

Consumers to get more detail about medical providers in health plans

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April 27, 2014

OLYMPIA, Wash. -- A new rule designed to give consumers increased information about health insurers’ provider networks was published today by Insurance Commissioner Mike Kreidler.

The new regulation applies to all state-regulated health plans offered both inside and outside of the Exchange, Wahealthplanfinder.

“I have heard from many consumers over the last several months who were upset to find their health plan no longer included their trusted doctor or hospital,” Kreidler said. “And some people only discovered this after they had enrolled.  This new rule increases transparency for consumers and gives my office better tools to evaluate an insurer’s ability to deliver health care services to its enrollees.”  

In addition to increasing transparency, the new rule harmonizes existing state regulations with the Affordable Care Act (ACA) and sets clear and uniform standards for how the Office of the Insurance Commissioner evaluates networks when they are initially filed and when changes to them are made.

Under the new rule, all health plans must:

  • Have an adequate number of medical providers and facilities to support delivery of and access to covered services without unreasonable delay.
  • Provide access to care in a timely manner and within reasonable proximity.
  • Ensure that medical providers who serve predominately low-income, medically underserved individuals (called, Essential Community Providers) are included, based on the needs of the population served.

The 2015 health plans and their proposed rates must be filed with Kreidler’s office by May 1. Insurers also must begin filing provider network reports. The new rule allows issuers time to provide this information to the OIC and to address network contracting issues.

Insurers will be required to supply detailed geographic information about their networks illustrating how they meet the needs of all of their enrollees, depending on where they live.   

Kreidler said the rule, in part, became necessary to deal with the emerging trend toward narrower networks of medical providers and facilities.

In this arrangement, insurers did not contract with some doctors and hospitals, an innovation designed to keep premiums as affordable as possible for consumers. While the new rule does not prevent insurers from innovating, it does require all networks to guarantee timely and adequate access to care.

Kreidler began the rule-making process last September and circulated two drafts of the proposed regulation for comments and received comments from over 70 different organizations, groups, and individuals. After hundreds of comments from insurers, medical providers, consumers, hospital representatives and other interested parties, a public hearing was held on the revised rule on April 22.   

“The Affordable Care Act increased benefits, but it also expanded the role consumers are expected to play when shopping for health insurance, said Kreidler. “It’s my job to give them the tools they need to be successful and to provide them with as much transparency as possible. I also want health insurers to innovate, especially if it helps keep costs down for consumers, but innovation cannot be at the expense of a consumer’s ability to access care."

Kreidler added, “We received a lot of feedback on this rule and no one got everything they wanted. We will evaluate the impact of this rule during the next year to see if adjustments are needed, but I can assure you that doing nothing or delaying was not an option. Ultimately, it’s my responsibility to create the tools we need to monitor the marketplace and protect consumers. I believe this rule gives us what we need.”

Washington state’s network rules date back to 1998 and have not been modified since 2003. The new rule takes effect on May 26.