The “skinny” on narrow networks…

The Advocacy Council continues to hear from practicing allergists about limited (also called narrow or “skinny”) managed care networks. These are provider networks, which may also include hospitals and other health care services, that limit their member coverage to only a few select providers. With the expansion of exchanges as the result of the Affordable Care Act (ACA), narrow networks have become more common and often seem to be directed at providers who treat chronic diseases (like allergies and asthma) or high cost centers, like tertiary care (often University) facilities. Because plans can no longer rate patients on the basis of risk, they must contend with the financial exposure of having a high-cost patient. One way to manage this risk and perhaps discourage patients with chronic conditions from selecting their plan is by limiting provider choice.

Because of the churn in health care plans, especially among employer groups, the beginning of the new year often brings the first realization to our patients that they are no longer able to see their preferred physician. For instance, we recently heard from a member who had been excluded from such a network. As a consequence, several long-term patients were having to not only switch their allergist/immunologist, but also, according to the allergist, required to travel much further (in this case over 50 miles) for treatment and follow-up.

Generally, the first line of “defense” on network adequacy standards is to investigate state law requirements which may impact both plans sold through the ACA exchanges and those sold on the non-exchange market, including to employers. In addition to state network adequacy requirements, there are separate ACA network adequacy requirements. ACA requirements would not supersede state network adequacy requirements but instead set minimum federal standards. If the state standards are more robust or higher, then ACA Plans sold in a state would have to meet the higher state standards. You can find out information about your state here.

Finally, Medicare, too, has network adequacy standards for Medicare Advantage plans. The Medicare advantage plans also have minimal standards for specialty access (including allergists/immunologists) related to both minimum specialist/patient ratios and maximum distance and travel times based on whether they serve metro, suburban or rural areas. With the current ACA “repeal and replace” discussions in Congress, the narrow network concept could be affected, but there is no certainty that it will go away, and there is always a risk that it will expand.

The Advocacy Council will continue to bring our concerns to Congress related to restriction of specialty care through skinny networks, but we need your help by keeping us informed of any issues in your market. We also suggest you contact both your state and federal legislative officials to express the concerns you have for your patients.

Advocacy Issue: 
Billing, Coding & Payments
Skinny Networks