The ACA and health insurance provider networks - what's new for 2016

What to know about health insurance provider networks
Want to make sure you can keep seeing your favorite doctors? There's a lot to know about provider networks. LWA/Dann Tardif/Blend Images/Getty Images

Provider networks have long been part of the equation when people are shopping for a health insurance plan. Some plans have broad networks, while others contract with far fewer providers. 

In general, the trend over the last few years has been towards narrower networks, with more carriers offering HMOs and EPOs, and fewer carriers offering PPOs. While PPOs are still available in most areas, there's also a trend towards narrower PPO networks.


Narrow networks

Narrow networks - which limit how many healthcare providers can participate - tend to allow carriers to offer lower premiums, since keeping networks narrow gives carriers more negotiating power when they're establishing payment rates for healthcare providers. That in turn allows carriers to offer lower premiums on their health insurance plans. 

Broad networks, on the other hand, tend to allow any providers to participate, as long as they agree to the terms of the network contract. But broad networks are becoming less common as carriers seek to use network negotiating power to keep premiums as low as possible.

Because the Affordable Care Act requires carriers to offer all plans to all applicants regardless of medical history, and because plan designs are much more standardized than they used to be, premiums are a primary way that carriers can differentiate their products. 

Tiered networks

In a tiered network design, insureds have lower out-of-pocket costs if they see a healthcare provider in the preferred tier.

They're also free to see providers in non-preferred tiers, with the understanding that their copays, deductible, and coinsurance will be higher in that case. New Jersey's exchange includes tiered network plans from Horizon Blue Cross Blue Shield for 2016; the plans are less expensive than other options, but their introduction has also been controversial.

In both narrow networks and tiered networks, health insurance carriers tend to use quality indicators to determine which providers will be included in the network, or in the preferred tier. A provider's quality of care, cost efficiency, and clinical outcomes can all be included in the decision-making process when carriers are seeking providers to be in their network.

Because limited provider networks tend to include the providers that offer the best quality care and health outcomes with the most efficient pricing, insureds still have access to high-quality care on narrow and tiered networks. In 2014, half of the plans sold through the exchanges had limited networks, but consumers tended to be happy with the coverage provided by limited network plans.

And although there have been criticisms of narrow networks, studies have found that patient outcomes don't seem to suffer when networks are limited in size.

New rules for 2016

In February 2015, CMS released guidelines on network adequacy and provider directories for 2016.

Limited networks are allowed, but carriers must “maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to assure that all services will be accessible to enrollees without unreasonable delay" 

Carriers that contract with the federally-run exchange ( are also required to maintain an accurate, up-to-date online provider directory starting in 2016 (most carriers have already been doing this, but it's a requirement in 2016). The directory must be easily accessible for the general public, which means no account creation or policy ID number can be required to access the provider directory. It must be updated at least monthly, and must include accurate information about the providers, including whether or not they're accepting new patients. For plans that use tiered networks, a provider's inclusion in a particular tier must be readily discernible from the provider directory.

Be aware, however, that provider networks can change throughout the year, which is why the directories are required to be updated at least monthly. Just because a provider participates in a plan's network when you enroll doesn't mean that will always continue to be the case throughout the year - it's important to check the provider directory before making an appointment for medical care. beta testing provider search feature

Early in the 2016 open enrollment period, announced that they are beta testing a new search feature that allows users to search for health plans based on the inclusion of a particular doctor or hospital in the plan's network. 

The search feature is being rolled out randomly to about a quarter of users, and those who opt-in to use it will be able to leave comments about the search tool that will use to improve it before it's made available to all site visitors.

Until that point, most applicants will need to use the provider directors links for each plan (described above) to ensure that their providers are included in the networks of the plans they're considering. If you need assistance, a broker or navigator can help you determine which plans include your doctors.

Surprise out-of-network charges

Even when patients make sure they use an in-network medical facility and doctor, they can be surprised after the fact to receive a bill for out-of-network charges. That's because not all providers at a hospital are contracted with the same health insurance carriers; you might have a surgery performed at an in-network hospital by an in-network surgeon, but the anesthesiologist or assistant surgeon might not be in your health insurer's network.

If you're going to be receiving care that's planned in advance, it's a good idea to discuss this issue with the billing department ahead of time, asking whether it's possible that anyone on the team that will be treating you is not contracted with your health insurance company.

Continue Reading