last update: October 7, 2022
"Network Adequacy" is a set of ideas related to the number of providers, the distance between those providers and the members, and other metrics, included "customer complaints."
Network Adequacy is a key driver for provider rates, as Medicaid payers (RAEs) and commercial insurance payers have network adequacy requirements that are set federally and by states, if those standards are enforced. While payers may increase the size of their networks through recruiting and outreach, the most common way to attract providers is to offer higher rates.
COMBINE collects definitions of Network Adequacy, and also analyzes the quarterly Network Adequacy reports published by HCPF.
DORA has a Division of Insurance that looks after commercial health insurance ("Title 10"). Medicaid ("Title 25-5") is managed by corporate RAEs and HCPF, and have their own standards.
Here's information about DOI network adequacy standards:
The Division's network adequacy standards can be found in Colorado Insurance Regulation 4-2-53. For ACA- compliant health benefit plans, health insurance companies submit their network adequacy filings to the Division in a platform called SERFF in July for the upcoming plan year. The Division reviews the network adequacy filings for compliance - specifically a form called the "Network Adequacy Summary and Attestation." This form is where a health insurance company attests to meeting the requirements in CRS 10-16-1704 and the Division's regulations. When a carrier attest to not meeting a standard, they must complete information that tells the Division how they will come into compliance.
CRS 10-16-704(1) has the definition of "a network that is sufficient...", Regulation 4-2-53 then attempts to start giving specific numerical standards (revised from the Federal standards).
In CO Insurance Regulation 4-2-53 on page 5 (of 17), network adequacy is partly defined as
Mental health, behavioral health and substance use disorder care providers 1:1000
HCPF contracts with corporate Regional Accountability Entities that manage Medicaid behavioral health care. The contracts are available.
Network adequacy is defined in these contracts. For example:
9.4.11. The Contractor shall ensure that its Provider Network meets the following practitioner to Client ratios and distance standards:
220.127.116.11. Adult primary care providers: One (1) practitioner per eighteen hundred (1,800) adult Members.
18.104.22.168. Mid-level adult primary care providers: One (1) practitioner per twelve hundred (1,200) adult Members.
22.214.171.124. Pediatric primary care providers: One (1) PCMP Provider per eighteen hundred (1,800) child Members.
126.96.36.199. Adult mental health providers: One (1) practitioner per eighteen hundred (1,800) adult Members.
188.8.131.52. Pediatric mental health providers: One (1) practitioner per eighteen hundred (1,800) child Members.
184.108.40.206. Substance use disorder providers: One (1) practitioner per eighteen hundred (1,800) Members.
COMBINE advocates for a standard definition of network adequacy, used by all Colorado administrative departments. Different standards create access inequities.