Exchange Plan Provider Networks: More Attention and Transparency Needed

In recent months, policymakers and the press have been paying a great deal of attention to the adequacy of provider networks offered in Affordable Care Act (ACA) health insurance exchanges, as well as the accuracy of plan provider directories. For example, complications in Missouri arose before the 2014 open enrollment period; one of the state’s largest health systems, which operated 13 hospitals including a nationally ranked children’s hospital, was not included in Exchange plan networks.  In California, consumers pursued lawsuits alleging that several health plans falsely advertised their networks on the grounds that they provided inaccurate and out-of-date provider directories. Concerns about provider participation are not confined to these complaints about the exclusion of certain facilities.

Breakaway Policy Strategies conducted significant research into provider networks offered through in the 2014 ACA’s exchanges.  Our research highlights provider directory features that could prove problematic for consumers. Generally, the directories lack consistent style, categorization, and search functionality across carriers.  These issues are not unique to one carrier or one market, and early research indicates these trends continue in 2015.

What follows is a brief summary of selected findings, and suggested ways to improve provider network search functionality.

Mental Health Provider Lists

Breakaway’s research found that carriers have no standard method for consumers to search for behavioral health, mental health, and substance abuse provider services.  Some plans allow a consumer to search only by specific specialty, while others allow the consumer to search only in the broad category of “mental health providers.” The latter generates extensive multi-provider-type listings with no differentiation of the different types of providers.  Further, some of these extensive lists exclude psychiatrists, but consumers are not informed that they must to search “psychiatrist” separately.   Similarly, in some plans, substance abuse treatment services are not included in a list of “mental health” providers.

Other Provider Searches by Specialty

Carriers have highly variable search mechanisms for non-behavioral health specialties.  Depending on the carrier, a search for “radiologist” can produce a consolidated list including all radiology sub-specialties, or the consumer may have to search by specific sub-specialty.  Each approach has merits and drawbacks, but the lack of consistency among search processes can pose a challenge to regulators and consumers.  If not aware of how a carrier’s search function is structured, a search for a certain medical specialty could be misleading or produce inaccurate results.

Accuracy and Completeness of Information

The information contained in some plan provider searches may be misleading or may not include all necessary information.  For example, Breakaway found inconsistencies between information in health plan Statement of Benefits and Coverage (SBC) and in the plan’s provider directory.  A plan SBC may indicate a tiered provider network, while the provider directory offers no information about tiering.  As a result, a provider may appear to be “in-network” under the directory when they are actually on a higher cost-sharing tier. A consumer may not be aware of the tiering, and the resultant cost-sharing, until s/he has enrolled in a plan.

The accuracy of information contained in provider directories, particularly in relation to providers accepting new patients, is critical information for consumers.  Our research indicates that the presentation of this information is not uniform, and consumers have no way to know if it is up-to-date.


Breakaway found a high instance of duplicate provider listings—multiple listings of the same provider, due to different practice locations or multiple subspecialties.  Duplication artificially inflates the number of in-network providers, which in reality may be less than half the number shown.  This has important implications for plans reporting the number of participating providers to regulators.

One carrier   limit search results to 200 physician names in all its plans in various markets reviewed.  Even where it is clear that the network includes additional providers, the search cannot be refreshed or modified to show the additional listings.  Further, Breakaway found the duplication rate for the 200 names was over 25% in one plan.

Search Area Parameters

Most plans allow provider searches by distance, but the distance search parameters are highly variable by plan–e.g. minimum and maximum mileage, and increments between the minimum and the maximum.  Further, some plans only permit searches by county, with no mileage radius.

Disorganized Display

Many provider search results are not displayed alphabetically, with some plans unable to sort listings alphabetically.  A consumer would turn up pages of providers containing duplicate listings, which are difficult to use without the ability to alphabetize.  Non-alphabetized search result displays can impede the consumer who is uncertain how to spell a provider’s surname.  S/he would have to wade through a large list to identify a particular provider.

CMS-Proposed Improvements for 2016

The Centers for Medicare and Medicaid Services (CMS) proposed improvements to qualified health plan (QHP) provider directories in its Notice of Benefit and Payment Parameters for 2016.[1]  The CMS proposal would require that provider directories are up to date, accurate and complete.  It includes a requirement that directories to be updated monthly, and that plans clearly show consumers which providers are participating in each specific plan.  In the notice of proposed rulemaking, CMS states it will defer finalizing provider network requirements until the National Association of Insurance Commissioners (NAIC) finalizes its Plan Network Access and Adequacy Model Act,[2] whose provider directory requirements generally mirror the CMS proposal.

Remaining Improvements for 2016 and Beyond

The CMS and NAIC proposals contain important improvements to the provider directories.  However, our research has illuminated additional areas for improvement.

1.  Standardize the provider directory search functions across all plans—at the national level, the regional level, the state level, or the market service level.

— Set alphabetic display of providers as the default, with all practice locations listed under the provider surname.

— Standardize the medical specialty search and display functionality.

i. Allow search at different specialty and sub-specialty levels.

ii. Create uniform terminology to describe specialties and sub-specialties.

— Provide information to consumers about practitioner types, specialties and sub-specialties.

— Standardize the distance search parameters across all plans–mileage with standard minimums, maximums and increments.

2. Require provider tier information to be displayed in a standard format, with links to an explanation of the out-of-pocket implications.

3. Consider remedies to ensure consumer protection such as:

— Provide “in-network” and (as appropriate) Tier 1 coverage of a provider if a consumer enrolls in a plan based on incomplete or inaccurate directory information regarding provider network participation status; or

— Allow a special enrollment period for any consumer who selected a plan based on outdated or inaccurate provider directory information.

There are straightforward problems with provider network directories that call for straightforward solutions.  Previously, plans did not have to attend to the accuracy and functionality of their provider directories, but today is different. Plans have been consumed with organizing offerings in the new markets and complying with new requirements, and provider directory issues have not been top tier issues.

However, going forward, consumer satisfaction with their plan selection and out-of-pocket payments will be quite contingent on the accuracy of the provider directory.  Therefore, the functionality of directories need to improve considerably. CMS has proposed improvements, but more can and should be done.


Jane Horvath is the Vice President for Breakaway Strategies.


[1] This proposal is open for comment until December 26, 2014.

[2] Open for public comment until January 12, 2015.

Morning Consult