Health Plan Network Adequacy


TMA believes narrow networks can make it harder for patients to see doctors and make early intervention more difficult.

Mass cuts in physicians from UnitedHealthcare Medicare Advantage and the continued proliferation of narrow networks raise concerns about continuity of care and interference with doctor-patient relationship.

TMA is also concerned that when doctors who perform procedures that few specialists provide are cut from networks, it can essentially make some expensive services non-covered services even if they are in a patient’s plan.

Latest Updates:

  • TMA representatives are meeting with major payers and state officials to express concerns about network adequacy.

  • TMA advocacy staff is working with the National Association of Insurance Commissioners in drafting model state network adequacy standards.

  • CMS rules will require Medicare Advantage plans and exchange plans to contact doctors and update provider directories every three months or face stiff fines beginning in 2016.

  • In April 2015, TMA urged the deputy commissioner of the Tennessee Department of Commerce and Insurance to support the American Medical Association’s approach to establishing measurable, quantitative standards to evaluate network adequacy and strong regulation of tiered networks.

  •  In October 2015, TMA signed onto a letter to the NAIC outlining its reasons for advocating that the draft model network adequacy act: 1) Require prior approval of networks before health plans are sold. 2) Require states to institute measurable quantitative standards for network advocacy. 3) Include stronger protections for tiered networks.

  • In May 2016, TMA advocacy staff participated in a stakeholders meeting organized by the Tennessee Department of Commerce and Insurance to discuss the final NAIC model act and the possibility of enacting similar network adequacy requirements in Tennessee.