A health plan provider network is a collection of individual providers, clinics, hospitals and ancillary services, such as home health services, that the health plan enrollee or member may use for health care services. The health plan company contracts with individual medical providers, clinics and hospitals to create its provider network(s). The enrollee or member will receive care provided by “in-network” providers at a reduced rate, but will pay more to see providers outside of the network.
What types of providers are included in a provider network?
Minnesota law requires that all provider networks include primary care providers such as family practice physicians and nurse practitioners, pediatricians, mental health providers such as psychiatrists, psychologists, and social workers, and general hospitals. Networks must also include specialists, including cardiovascular, gastroenterology, obstetrics and gynecology, neurology, surgery, and a range of other specialists. At least one pediatric specialty hospital and one organ transplant surgery center must be included in each provider network.
Why does MDH review health plan provider networks?
The Minnesota Department of Health reviews provider networks to be sure that there are enough providers and the right type of providers in each network, and to determine whether consumers can get to a health care professional, clinic or hospital within a reasonable amount of travel time and distance.
Health plans must ensure that their enrollees or members have access to primary care providers (including pediatricians), mental health, and general hospital services within 30 miles or 30 minutes from all parts of the health plan’s service area. A “service area” is a group of counties that are served by the health plan. Specialty health care services must be available within 60 miles or 60 minutes from all parts of the health plan’s service area. Minnesota law requires health plans to include sufficient numbers and types of providers to provide all services for covered benefits.
There are certain providers that I like to see when I have a health care concern. Why is a specific provider either included or excluded from the provider network that is offered to me by my health plan company?
There may be a number of reasons why an individual health care provider, clinic or hospital is included or excluded from the health plan’s provider network. Health plan companies need to be sure that they include a sufficient number and type of providers so that they can cover all services promised in their benefits and coverage information. However, health plan companies may also consider the cost and quality of health care services. In some cases the health plan and the health care provider cannot reach an agreement regarding the fees that should be paid for health care services.
Health plan companies are not required to contract with any particular provider as long as they have an adequate network. There is an exception for “essential community providers” (ECPs). These are providers that meet certain criteria for providing services to underserved or special needs populations. Health plan companies must contract with ECPs if certain conditions are met.
How often does MDH review health care provider networks to determine if they are adequate?
For health plans marketed to individuals/families and small employers, health care provider networks are reviewed at least once annually to determine if they meet network adequacy standards. Some situations may require additional reviews of provider networks offered by a health plan. If the health plan company terminates contracts with a number of providers within the health plan’s provider network or with a hospital or large clinic system, MDH will request that the health plan company provide additional information so that we can determine whether the provider network can still serve the needs of the health plan’s enrollees or members. Additionally, if MDH receives consumer complaints indicating that an enrollee or member cannot access certain services within a reasonable period of time, MDH may request that the health plan company provide information to assess network adequacy, and may require that the company obtain contracts with new providers of needed health care services.
What if a provider who is listed in my plan’s network cannot see me as a patient?
The health plan company is required to have an adequate number of available providers in the network. However, not all providers may be taking new patients. If you have a problem seeing a provider who is in your network, you may call the health plan company for assistance and referral to another provider.
Can the health plan company change which providers are included in the networks?
As long as the health plan provides all required provider types and services in their network, a health plan company can change which specific providers are available within their network. However, the company must provide adequate notice to all enrollees or members that their current provider may no longer be available to them (as well as to the Minnesota Department of Health). Additionally, in certain cases the company must also assure that health care services and benefits will continue to be covered, and certain health conditions and illnesses require that the company allow the enrollee or member to continue seeing the same provider at the in-network cost, even if the specific provider is no longer available in the health plan provider network.