American Society of Plastic Surgeons
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NAIC Considers Network Adequacy Standards

The National Association of Insurance Commissioners (NAIC) is currently in the process of updating its Health Benefit Plan Network Access and Adequacy Model Act for the first time since 1996.

NAIC, a standard-setting and regulatory support organization, is governed by the head insurance regulators in all fifty states. States often adopt NAIC's model laws and regulations, which makes it worthwhile for affected stakeholders to provide input during the drafting process.

ASPS joined other provider groups in sending a comprehensive letter to Kansas Insurance Commissioner Sandy Praeger and Wisconsin Commissioner Ted Nickels. Commissioners Praeger and Nickels are key individuals within NAIC on the topic of network adequacy, as they chair the NAIC committees that are considering the model law.

The letter highlighted six key principles on which network adequacy standards must be built:

  • First, provider networks must include a full range of primary, specialty and subspecialty providers for children and adults to ensure that consumers have access to all covered services, at every level of complexity, without administrative or cost barriers.
  • Second, regulators must actively review and monitor all networks using appropriate quantitative and other measurable standards.
  • Third, appeals processes must be fair, timely, transparent and rarely needed. Appeals and other out-of-network arrangements must not be used as an alternative to an adequate network for all covered services.
  • Fourth, the use of tiered provider networks and formularies must be regulated to ensure that consumers of all ages have access to all covered services, including specialty services, without additional cost sharing or administrative burdens.
  • Fifth, insurers must be unequivocally transparent in provider selection standards.
  • Finally, provider directories must be accurate, up-to-date and easily accessible.

In addition, ASPS is working with the Alliance of Specialty Medicine to submit an additional letter from that group. Comments on the draft model close on January 12, 2015, and the committee is expected to discuss and potentially adopt the revised model at its March meeting in Phoenix, Ariz.