Regulation of Provider Networks in Response to COVID-19

ABSTRACT

In public health insurance programs, federal and state regulators use network adequacy standards to ensure that health plans provide enrollees with adequate access to care. These standards are based on provider availability, anticipated enrollment, and patterns of care delivery. We anticipate that the coronavirus disease 2019 pandemic will have 3 main effects on provider networks and their regulation: enrollment changes, changes to the provider landscape, and changes to care delivery. Regulators will need to ensure that plans adjust their network size should there be increased enrollment or increased utilization caused by forgone care. Regulators will also require updated monitoring data and plan network data that reflect postpandemic provider availability. Telehealth will have a larger role in care delivery than in the prepandemic period, and regulators will need to adapt network standards to accommodate in-person and virtual care delivery.

Am J Manag Care. 2021;27(4):e101-e104. https://doi.org/10.37765/ajmc.2021.88614

Takeaway Points

The coronavirus disease 2019 pandemic will have 3 main effects on provider networks and their regulation: enrollment changes, changes to the provider landscape, and changes to care delivery.

• Plans will need to adjust their network size to accommodate increased enrollment or increased utilization caused by forgone care.
• Regulators will also require updated monitoring data and plan network data that reflect postpandemic provider availability.
• Telehealth will have a larger role in care delivery than in the prepandemic period, and regulators will need to adapt network standards to accommodate in-person and virtual care delivery.

In public health insurance programs, regulators use network adequacy standards to ensure that health plans provide enrollees with adequate access to care. Standards are based on provider availability, anticipated enrollment, and patterns of care delivery, all of which are affected by the ongoing coronavirus disease 2019 (COVID-19) pandemic. COVID-19 affects how individuals in public health insurance programs access, pay for, and utilize health care beyond the pandemic. Regulators may need to modify network adequacy standards and monitoring processes to ensure beneficiary access in this changing health care landscape, particularly in light of prior work showing that many plans have narrow networks^1-3 and that network design affects beneficiary access to care.^4-8 We provide an overview of federal and state network adequacy standards and discuss how regulators may adapt these standards and accompanying monitoring processes in response to COVID-19.

Overview of Network Adequacy Standards

Network adequacy can be measured in several ways: the number of providers contracted by a health plan for a set of critical specialties, provider capacity (eg, number of beds, wait times to see a provider), and/or geographic coverage of the network (eg, maximum travel time/distance to a provider). Within this framework, regulators have developed network adequacy standards to monitor provider networks for Medicaid managed care, qualified health plans (ie, exchange or Marketplace plans), and Medicare Advantage (MA) plans.

The 2016 Medicaid Managed Care Final Rule required that states propose time/distance standards for a minimum set of provider specialties.⁹ Additionally, several states include quantitative measures of provider capacity, such as appointment availability and wait times.

States are tasked with primary oversight of network adequacy for qualified health plans.¹⁰ Although a few states, such as Colorado,¹¹ Delaware,¹² Idaho,¹³ and South Dakota,¹⁴ have established quantitative network adequacy standards for qualified health plans, many states simply rely on their criteria for commercial health plans. Criteria vary by state, but typical commercial criteria include a subset of standards for provider and facility specialties, minimum number of providers, geographic access standards, and appointment wait times.

MA network adequacy criteria comprise the most comprehensive set of standards compared with those for state Medicaid or qualified health plans. CMS measures (1) the minimum number of providers required in a county based on the penetration of MA plans in counties with similar population and density and (2) a sufficient number of providers to ensure that at least a specified percentage of beneficiaries have access to at least 1 of each provider and facility type within a maximum time/distance traveled based on the urbanicity of the market. Historically, plans have been required to cover 90% of beneficiaries for these 2 standards.

As part of the final rule published June 2, 2020, making technical changes to the MA program, CMS lowered to 85% the proportion of beneficiaries in nonurban counties that should have access to a provider within the maximum time/distance.¹⁵ Further, MA plans are eligible for a 10-percentage-point credit toward the proportion of beneficiaries residing within required time/distance standards when they contract with selected telehealth providers. The following provider specialties are among those that MA plans can contract with for telehealth services and obtain a credit toward their network determination: dermatology, psychiatry, cardiology, otolaryngology, neurology, ophthalmology, allergy and immunology, nephrology, primary care, gynecology/obstetrics, endocrinology, and infectious diseases. Finally, MA plans are eligible for an additional 10-percentage-point credit for each facility type or clinical specialty included in MA network adequacy criteria that is subject to state-level Certificate of Need requirements (Figure¹⁵).

Effects of COVID-19 on Developing and Monitoring Provider Networks

We have identified 3 primary considerations for monitoring provider networks in response to the COVID-19 pandemic: (1) insurer and regulator considerations for enrollment surges, (2) the changing landscape of available providers as a result of COVID-19, and (3) how COVID-19 has systemically changed the delivery of health care.

Enrollment surges. The economic downturn from COVID-19 will increase enrollment in critical public health insurance programs. When individuals lose employer-sponsored insurance, they may choose to enroll in a qualified health plan or, if they meet the eligibility criteria, they may enroll in Medicaid coverage. Economic downturns also increase the number of individuals who apply for and receive Social Security Disability Insurance (SSDI).^16,17 After 24 months of eligibility for SSDI, individuals may enroll in Medicare coverage. Increases in enrollment will require plans to increase the breadth of their provider networks or increase the capacity of their existing networks. Job loss–driven enrollment increases in Medicaid, qualified health plans, and eventually MA plans will mean that public payers cannot rely on historical enrollment projections to determine the minimum number of providers. Policy makers will need to make sure that their existing minimum provider thresholds ensure sufficient capacity for increased enrollment or update these thresholds to secure adequate access to care for additional enrollees. In instances in which it is not feasible to quickly change minimum number standards, regulators may rely on increased monitoring activities, such as “secret shopper” calls to monitor wait times.

Changes to provider landscape. To slow the spread of COVID-19, localities issued emergency public health orders, including physical distancing rules and prohibitions on elective procedures. Additionally, many individuals chose to forgo medical care to reduce their risk of exposure to COVID-19.¹⁸

Many outpatient practices temporarily closed in response to COVID-19; some may close permanently due to the financial strain, and others may be purchased by a larger organization.^19,20 Small and rural hospitals, which were already financially vulnerable before COVID-19, may also close.^21,22 This will change the number and location of providers and hospitals available to participate in provider networks. Practice acquisitions may also consolidate negotiating power among a more limited number of provider practices. Insurers and regulators will need to ensure that shuttered practices and hospitals are not included in provider directories or submitted to regulators in plan oversight materials (such as the MA Health Service Delivery [HSD] tables).²³

Regulators often compare contracted networks of providers to the landscape of providers serving a market.²³ Regulators will need to update their data files documenting provider availability to capture post–COVID-19 changes. Data lag for files such as Physician Compare and the National Plan and Provider Enumeration System (NPPES) means that these data sources will likely be an inaccurate source of provider office location information post pandemic. Although plans are expected to maintain current provider directory and network information, audits show that plan data are often inaccurate.²⁴ As a result, claims data from after the pandemic will be the most accurate and timely source of provider practice location information. Claims data from the period prior to the pandemic can provide a reliable source of information about provider specialties. Relying on data from the height of the pandemic, which will reflect disruptions in delivery patterns, including temporarily closed practices and primary care or office-based specialists temporarily serving in the inpatient setting, could lead to inadequate or less accessible networks, or erroneous assumptions about provider services and locations.

Changes to care delivery. In response to the COVID-19 pandemic, providers have transitioned to delivering many nonemergency/outpatient physical and mental health visits through telehealth.²⁵ From the week of March 2, 2020, to the week of April 13, 2020, telehealth utilization for Medicare enrollees increased by more than 11,000%, from 11,000 beneficiaries to more than 1.3 million beneficiaries receiving care through telehealth.²⁶ Insurers have supported this transition by rapidly moving to increase reimbursement for telehealth services and by loosening payment rules for the types of care that can be delivered via telehealth.^27,28 States have also loosened licensing laws, e-prescribing laws, and written consent laws to allow health professionals to deliver additional services through telehealth.²⁹ It is unlikely that telehealth utilization will return to pre–COVID-19 levels, and plans are likely to seek a greater role for telehealth in their networks.³⁰ Plans may prefer to partially replace in-person care with telehealth visits and narrow in-person networks accordingly. To maintain beneficiary access, policy makers will need to ensure that networks retain sufficient capacity through both telehealth and in-person visits. The federal government and states may consider making permanent the temporary waivers that enabled broader care delivery through telehealth.²⁷ In the June 2020 final rule,¹⁵ CMS loosened in-person network standards for MA plans that offer telehealth. State regulators may want to follow a similar approach for Medicaid managed care and qualified health plans.

Many individuals forwent care during the initial months of the pandemic.^18,31,32 As the pandemic subsides, the elective surgeries, screening procedures, and routine care that individuals put off during the pandemic will resume. There may also be an increase in utilization as a result of complications from forgone care for chronic conditions. Narrow networks with limited provider capacity may be insufficient to address the surge in enrollee demand for care. As described earlier, regulators may need to increase minimum number requirements or increase monitoring.

Conclusions

COVID-19 has dramatically changed health care delivery and will have effects on access to, and utilization of, health care services beyond the pandemic. Regulators that oversee provider networks for public insurance plans may need to take a more active role in adapting and using network adequacy monitoring tools for the next several years.

Author Affiliations: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (KEA), Baltimore, MD; The Lewin Group (LRS, KD), Falls Church, VA.

Source of Funding: This work was supported in part by grant number T32HS000029 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Author Disclosures: As a former employee of The Lewin Group, Ms Anderson conducted contract research for CMS on provider network adequacy standards. As employees of The Lewin Group, Dr Shugarman and Ms Davenport conduct contract research for CMS on provider network adequacy standards.

Authorship Information: Concept and design (KEA, LRS, KD); analysis and interpretation of data (KEA); drafting of the manuscript (KEA, LRS, KD); critical revision of the manuscript for important intellectual content (KEA, LRS, KD); administrative, technical, or logistic support (LRS).

Address Correspondence to: Kelly E. Anderson, MPP, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Rm 428, Baltimore, MD 21205. Email: kelly.anderson@jhu.edu.

REFERENCES

1. Skopec L, Berenson RA, Feder J. Why do Medicare Advantage plans have narrow networks? Urban Institute. November 2018. Accessed June 14, 2020. https://www.urban.org/sites/default/files/publication/99414/why_do_medicare_advantage_plans_have_narrow_networks.pdf

2. Wallace J, Lollo A, Ndumele CD. Comparison of office-based physician participation in Medicaid managed care and health insurance exchange plans in the same US geographic markets. JAMA Network Open. 2020;3(4):e202727. doi:10.1001/jamanetworkopen.2020.2727

3. Polsky D, Weiner J. The skinny on narrow networks in health insurance Marketplace plans. University of Pennsylvania ScholarlyCommons. June 23, 2015. Accessed June 14, 2020. https://repository.upenn.edu/cgi/viewcontent.cgi?article=1002&context=ldi_databriefs

4. Jumah F, Atanassova T, Raju B, et al. Do narrow networks affect the delivery of outpatient care in neurosurgery? a statewide analysis of Marketplace plans in New Jersey. World Neurosurg. 2020;141:e213-e222. doi:10.1016/j.wneu.2020.05.086

5. Haeder SF, Weimer DL, Mukamel DB. Going the extra mile? how provider network design increases consumer travel distance, particularly for rural consumers. J Health Polit Policy Law. 2020;45(6):1107-1136. doi:10.1215/03616878-8641591

6. Gruber J, McKnight R. Controlling health care costs through limited network insurance plans: evidence from Massachusetts state employees. Am Econ J Econ Policy. 2016;8(2):219-250.

7. Atwood A, Lo Sasso AT. The effect of narrow provider networks on health care use. J Health Econ. 2016;50:86-98. doi:10.1016/j.jhealeco.2016.09.007

8. Yasaitis L, Bekelman JE, Polsky D. Relation between narrow networks and providers of cancer care. J Clin Oncol. 2017;35(27):3131-3135. doi:10.1200/JCO.2017.73.2040

9. Network adequacy standards. 42 CFR § 438.68 (2016).

10. Patient Protection and Affordable Care Act; HHS notice of benefit and payment parameters for 2019. Fed Regist. 2018;83(74):16930-17071.

11. Colorado Code of Regulations. Emergency regulation 19-E-03: network adequacy standards and reporting requirements for ACA-compliant health benefit plans. Google Drive. Accessed July 21, 2020. https://drive.google.com/file/d/1SyvRYdVYOF7ODW2OwNcMHjPwwPcDhE9E/view

12. QHP standards for plan year 2018. Delaware Health and Social Services. December 1, 2016. Accessed July 21, 2020. https://dhss.delaware.gov/dhcc/files/qhpapprovedstandards2018.pdf

13. 2020 Idaho standards for Affordable Care Act compliant individual and small group health benefit plans and qualified dental plans. State of Idaho Department of Insurance. April 26, 2019. Accessed July 21, 2020. https://doi.idaho.gov/DisplayPDF?Cat=company&ID=2020%20Idaho%20ACA%20HBP%20and%20QDP%20Standards

14. SD Codified Laws §58-17F-5. Accessed July 21, 2020. http://sdlegislature.gov/Rules/DisplayRule.aspx?Rule=20:06:55:37

15. CMS, HHS. Medicare program; contract year 2021 policy and technical changes to the Medicare Advantage program, Medicare Prescription Drug Benefit program, and Medicare Cost Plan program. Fed Regist. 2020;85(106):33796-33911.

16. Maestas N, Mullen KJ, Strand A. Disability insurance and the Great Recession. Am Econ Rev. 2015;105(5):177-182. doi:10.1257/aer.p20151089

17. Black D, Daniel K, Sanders S. The impact of economic conditions on participation in disability programs: evidence from the coal boom and bust. Am Econ Rev. 2002;92(1):27-50. doi:10.1257/000282802760015595

18. Anderson KE, McGinty EE, Presskreischer R, Barry CL. Reports of forgone medical care among US adults during the initial phase of the COVID-19 pandemic. JAMA Netw Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882

19. Dafny L, McWilliams JM. Primary care is hurting: why aren’t private insurers pitching in? Health Affairs. May 21, 2020. Accessed June 4, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200519.916904/full/

20. Basu S, Phillips RS, Phillips R, Peterson LE, Landon BE. Primary care practice finances in the United States amid the COVID-19 pandemic. Health Aff (Millwood). 2020;39(9):1605-1614. doi:10.1377/hlthaff.2020.00794

21. Chartis Center for Rural Health. The rural health safety net under pressure: rural hospital vulnerability. The Chartis Group. February 2020. Accessed June 5, 2020. https://www.ivantageindex.com/wp-content/uploads/2020/02/CCRH_Vulnerability-Research_FiNAL-02.14.20.pdf

22. Hospitals and health systems face unprecedented financial pressures due to COVID-19. American Hospital Association. May 2020. Accessed June 5, 2020. https://www.aha.org/system/files/media/file/2020/05/aha-covid19-financial-impact-0520-FINAL.pdf

23. Medicare Advantage and section 1876 cost plan network adequacy guidance. CMS. February 20, 2018. Accessed June 5, 2020. https://www.cms.gov/files/document/medicare-advantage-and-section-1876-cost-plan-network-adequacy-guidance-pdf.pdf

24. Online provider directory review report. CMS. November 28, 2018. Accessed June 14, 2020. https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf

25. Parisien RL, Shin M, Constant M, et al. Telehealth utilization in response to the novel coronavirus (COVID-19) pandemic in orthopaedic surgery. J Am Acad Orthop Surg. 2020;28(11):e487-e492. doi:10.5435/JAAOS-D-20-00339

26. Pifer R. Medicare members using telehealth grew 120 times in early weeks of COVID-19 as regulations eased. Healthcare Dive. May 27, 2020. Accessed July 21, 2020. https://www.healthcaredive.com/news/medicare-seniors-telehealth-covid-coronavirus-cms-trump/578685/

27. Trump administration issues second round of sweeping changes to support U.S. healthcare system during COVID-19 pandemic. News release. CMS; April 30, 2020. Accessed June 5, 2020. https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid

28. Health insurance providers respond to coronavirus (COVID-19). America’s Health Insurance Plans. Updated February 24, 2021. Accessed June 5, 2020. https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

29. Weigel G, Ramaswamy A, Sobel L, Salganicoff A, Cubanski J, Freed M. Opportunities and barriers for telemedicine in the U.S. during the COVID-19 emergency and beyond. Kaiser Family Foundation. May 11, 2020. Accessed June 5, 2020. https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/

30. CMS-1744-IFC, Medicare and Medicaid programs; policy and regulatory revisions in response to the COVID-19 public health emergency. Federal Trade Commission. May 29, 2020. Accessed June 5, 2020. https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-letter-centers-medicare-medicaid-services-regarding-interim-final-rule-policy-regulatory/v200009_staff_advocacy_letter_cms_telehealth_comment.pdf

31. Gonzalez D, Zuckerman S, Kenney GM, Karpman M. Almost half of adult families losing work during the pandemic avoided health care because of costs or COVID-19 concerns. Urban Institute. July 10, 2020. Accessed July 14, 2020. https://www.urban.org/research/publication/almost-half-adults-families-losing-work-during-pandemic-avoided-health-care-because-costs-or-covid-19-concerns

32. Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e2024984. doi:10.1001/jamanetworkopen.2020.24984