Commercial Payers → Delivery → Network Management

 
 

Network Management


Most network adequacy standards are regulated at the state level and vary between states. Therefore, it is necessary to become familiar with the network adequacy standards in your state to determine if they apply to the National Diabetes Prevention Program (National DPP) lifestyle change program.

Typically, network adequacy standards only apply to benefits offered as part of a commercial plan’s core benefit offerings, and not to value-added, supplemental, or optional services offered by non-specialized practitioners outside of the core benefits. Consequently, if plans offer the National DPP lifestyle change program as a value-added benefit, it is unlikely that network adequacy standards would apply.

That said, commercial plans should review if and how applicable state-specific network adequacy standards apply to a program like the National DPP lifestyle change program.

 


 

State Standards

Nearly every state has flexible qualitative network adequacy standards such as requiring networks to be “sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without reasonable delay.” For more information see Regulation of Health Plan Provider Networks.

However, more than half of states have also implemented objective quantitative tests of network adequacy. Common quantitative standards include:

  • Maximum time and distance enrollees travel to access services
  • Types of providers available to enrollees
  • Maximum length of time enrollees wait for appointments for nonemergency services
  • Ratios of providers to enrollees

Commercial plans, self-insured employers, and the CDC-recognized organizations they contract with to provide the program should be aware of all state network adequacy statutes and regulations in states where they operate. For quick reference, a summary of network adequacy standards developed by the National Conference of State Legislatures is available here (dated 02/01/2018).

 


 

Contracting with CDC-Recognized Organizations

It is important to note that meeting network adequacy standards can be an issue when CDC-recognized organizations are not uniformly available to a plan’s members across the state. Online or distance learning programs may be able to be used to compensate for this.

It is also important to note that even though CDC-recognized organizations have experience with meeting CDC’s Diabetes Prevention Recognition Program (DPRP) standards, many of these organizations will likely be new to commercial plan or employer networks may not understand standard contracting procedures. Additional time and/or training may be necessary to assist these organizations.

 


 

Federal Standards for Qualified Health Plans

Section 1311(c) of the Affordable Care Act (ACA) introduced federal network adequacy standards for individual market and small group commercial plans that are Qualified Health Plans.

Qualified Health Plans are required to have a provider network that:

  1. Includes essential community providers in accordance with 45 CFR 156.235;
  2. Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay; and
  3. Is consistent with the network adequacy provisions of section 2707(c) of the Public Health Service Act.

A Center for Medicare & Medicaid Services (CMS) letter describing how this standard will be applied in 2017 is available here.

These federal rules serve as a “regulatory floor,” but states have the latitude to retain authority over enforcing network rules. Therefore, state network standards also apply to Qualified Health Plans.

 


 

Leveraging State Public Health Departments

Commercial plans and employers should consider leveraging their state public health department to help connect them with the CDC-recognized organizations in the state. Many public health organizations and agencies have been involved in initiatives related to scaling and sustaining the National DPP lifestyle change program, including delivering the program themselves in areas that do not have access to CDC-recognized organizations. For more information, see the Additional Initiatives section.