Wisconsin OCI Releases New Study Analyzing Network Adequacy
Madison, Wis. — The Office of the Commissioner of Insurance (OCI) has released the final report in a series of studies commissioned to evaluate the individual health insurance market in Wisconsin.
“These reports have helped us understand health plan designs, consumer experience, and enrollment," said Insurance Commissioner Nathan Houdek. “As the 2024 Open Enrollment period is under way, the findings of these reports continue to guide and inform our work to increase access to health care in Wisconsin."
The Wisconsin Individual Health Insurance Market Analysis found that the individual health insurance market has expanded substantially statewide, growing 8% from 2019 to 2021. Yet, it also found that an estimated 312,000 Wisconsinites are still uninsured.
The report evaluating the utilization and impact of short-term limited duration plans found that enrollment in these short-term plans has been decreasing in recent years, which may be due to the expanded federal subsidies for ACA-compliant plans on the individual health insurance marketplace.
The final report in this series evaluated network adequacy, which refers to a health insurers' ability to deliver covered benefits by providing reasonable access to enough in-network providers. Regulation of network adequacy can involve standards like maximum time or distance to travel to providers, maximum wait times, and minimum ratios of providers to enrollees.
The report has several key findings:
Health insurers identified challenges meeting federal network adequacy standards in up to 40 of Wisconsin's 72 counties. The causes for these challenges could include provider networks being under development, a lack of providers in a given specialty practicing within the time and distance standards of a county, or providers in a given specialty contracting exclusively with another organization.
In 52 counties, health insurers' networks do not meet Centers for Medicare and Medicaid Services (CMS) standards for pediatric primary care access. This access standard is impacted by the manner in which rural patients access care, which is often through a family practitioner rather than a pediatrician. CMS does not allow family practice physicians to count toward meeting network adequacy for pediatrics primary care.
In 34 counties, health insurers' networks do not meet CMS standards for OB/GYN access. CMS' definition of OB/GYN services requires the presence of pediatricians and obstetricians-gynecologists. In rural areas, family practitioners are more likely than urban family practitioners to provide obstetrical deliveries, newborn care, and pediatric care.
Five out of 14 health insurers reported access challenges in crisis behavioral health services.
Four out of 14 health insurers identified challenges in access for alcohol and other drug abuse services. These challenges included wait times for new appointments, limited number of credentialed treatment providers, and a shortage of available beds.
Eight of the 14 health insurers identified strategies they are deploying to address mental health and substance use disorder challenges which included expanding telehealth options for mental health services and paying for services delivered by out-of-network providers.
“The findings in this report will assist us in our work to ensure that every person who enrolls in health insurance coverage can access the care covered by their plan," said Commissioner Houdek. “The network adequacy standards and ACA coverage requirements apply to the health insurance plans on HealthCare.gov. Enrollment is open right now, so don't miss your chance to get high quality coverage for you, your family, or your small business."
Consumers are encouraged to visit WisCovered.com, a digital resource for Wisconsinites to learn more about their coverage options and get connected with free, local experts that are here to help.
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This study was conducted thanks to funding through the State Flexibility to Stabilize the Market Cycle II Grant Program (State Flexibility Grant) administered by the Centers for Medicare and Medicaid Services. State Flexibility Grant funds can be used for a variety of planning and implementation objectives related to the selected market reforms and consumer protections such as developing actuarial and economic analyses and performing market scans of the states' health insurance market to improve and expand the number of coverage options. OCI commissioned three reports funded by the State Flexibility Grant including the Market Analysis, a study of short-term limited duration plans, and a review of network adequacy. Wisconsin's State Flexibility Grant has a project period that ends September 14, 2023.
The publication was supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $689,458.16 with 100% funded by CMS/HHS and $0 and 0% funded by non-government source(s). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS or the U.S. Government.