Ensure network adequacy in employer-based plans

Individuals needing MH/SUD services often face difficulties finding and accessing in-network providers. This can result in long wait times, high out-of-pocket costs, and inadequate care. While some states have established their own network adequacy standards for MH/SUD providers, such as timely access and geographic distance standards or provider-to-enrollee ratios, these standards vary widely. And even in many states that have standards, they are qualitative, rather than quantitative in nature, significantly impairing enrollees’ rights and making the standards difficult to measure or enforce.[1] Additionally, large employers often self-fund their plans, which are subject only to federal law and are not required to meet timely access or geographic distance standards.

While federal policymakers are working to require stronger network adequacy standards for Medicaid, Medicare, and individual marketplace plans, individuals in large employer-based plans should not be without protections. Congress should establish uniform, quantitative timely access and distance standards for MH/SUD services for all employer-based plans nationwide. If a plan’s network is unable to provide needed MH/SUD services for an enrollee within these standards, the plan should be required to arrange out-of-network services with the enrollee’s cost-sharing limited to what they would have paid had in-network services been available. Numerous states have implemented such standards, including California, which requires that health plans have medically necessary MH/SUD services available within 10 days.[2] More than a dozen other states have mandated quantitative time and distance standards.[1]