NYS Council on Network Adequacy

April 13, 2023

Advocates and providers across New York have long argued for the State to update and liberalize its standards for insurers’ provider networks, AND ENFORCE THEM, for both public programs and private insurance.  Too many insurers’ networks are WAY too narrow and shallow, all just to game the system and rake in the cash from either taxpayers, individuals and families, or small business owners.  These networks limit access to care, and force people to leave their existing providers who know them and their health history, or have to pay fully out of pocket to keep seeing them.  Across the country the proportion of beneficiaries who are forced to go out of network in order to find behavioral health care is significantly higher than the rate for those seeking physical health services.  

As you know, the Governor’s proposed executive budget includes a proposal in the Article VII, Health/Mental Hygiene bill, Part II, subpart F, that would require the state to update Network Adequacy standards, and in instances where an insured with commercial insurance cannot find an appropriate ‘in-network’ mental health or substance use disorder provider, require the insurer to pay the out of network provider who agrees to serve the beneficiary, at the Medicaid rate.   In our opinion this proposal is a good start but without robust surveillance, monitoring and enforcement of all Network Adequacy standards, the likelihood of an insurer changing its behavior significantly, is poor.   That’s why the NYS Council has been fighting for the addition of proposed language to be added to the Network Adequacy proposal that would increase the penalties on insurers who fail to meet the standards.  Needless to say, this is an uphill climb.  

An NPR news story recently reported on the Network Adequacy crisis.  On the national level, nearly TWO-THIRDS of insurers’ networks failed the existing meager standards:


Here is the recent GAO report on the matter, referenced by the NPR story:


Finally, here is the proposed language the NYS Council will continue to push – to ensure compliance by insurers, as well as adequate surveillance, monitoring and enforcement by the state, for your information.  At the present time, it is unlikely our language will be included in the final enacted state budget but we will continue to press hard:

  • The state must perform a quarterly analysis of Provider Network Data Set (PNDS) data without fail. DoH must analyze the data aggregated by MCO and also by service type.
  • Results of the analysis (citing each plan by name) as well as the methodology used to calculate NA, and the immediate action taken by the state must be published on DoH website and be easily accessible to the public.
  • If the plan fails to meet Network Adequacy standards per the Model Contract, this should automatically result in regulatory action by the state, without exception. The regulatory action must include fines of no less than $10,000 per instance of non-compliance.
  • If the plan fails to meet Network Adequacy standards 3 times in one year, the state must prohibit the MCO/plan from enrolling new insureds for a period of no less than 6 months. 

We will keep you apprised of developments related to the 6 insurance proposals in the Health/Mental Hygiene bill under Part II as budget negotiations continue.