CMS pilot program for judging breadth of narrow networks

How Narrow Is It? Gov’t Begins Test Of Comparison Tool For Health Plan Networks

By Michelle Andrews
Kaiser Health News, October 14, 2016

The incredible shrinking provider network is nothing new in marketplace plans. One way insurers have kept premiums in check on the individual market is by reducing the number of providers available in a plan’s network. Earlier this year, the federal government said that it would introduce a tool this fall to help consumers who are shopping on gauge how narrow a plan’s provider network is compared with others in the area.

But most consumers who want that information will have to wait at least another year. The Department of Health and Human Services recently announced that the pilot project to test the network breadth tool just got a little, well, narrower.

Consumers can already check whether specific doctors or hospitals are included in a marketplace plan’s provider network on But there’s currently no way to easily measure the breadth of a plan’s provider network. This can be an important factor for some consumers, especially given the growing number of plans with no out-of-network benefits.

The new tool will designate marketplace health plan networks as “basic,” “standard” or “broad” based on how they compare with other health plan networks in a county. The label will reflect the availability of three types of providers: primary care, pediatricians and hospitals.

Originally, network-breadth information was going to be available for the 35 states on, the federally facilitated marketplace. But in August HHS announced it would make the tool available in just six unnamed states.

In September, HHS said it would shrink the pilot still further, to four states — Maine, Ohio, Tennessee and Texas.

Although the tool will let people compare networks in their area, still, “it’s all relative,” (Georgetown Professor Sabrina) Corlette said. “If you’ve got a market where every single network is narrow, this network breadth rating is less useful.”

CMS update on the network breadth pilot program:



By Don McCanne, M.D.

One of the major concerns with the implementation of the Affordable Care Act is that many of the exchange plans have narrow to ultra-narrow provider networks. Since it is difficult to determine the breadth of providers included, CMS is providing a network rating system to provide more transparency, as if the problem of narrow networks wasn’t much more serious than simply lack of adequate information.

The fact that the pilot program was pared back suggests that this will not be a simple process. It will be difficult to match a fluctuating provider list with the medical needs of the plan enrollees. Further, since each enrollee has different medical needs, it will be even more difficult to be certain that the needs of each enrollee will be met, even if the enrollees’ preferences are ignored.

Although a recent report suggests that plans with narrow networks have premiums that are about 7 percent lower than plans with broad networks, once most insurers switch to narrow networks, that differential will go away.

But this is typical of CMS. When the problem is that insurers are limiting patients’ choices in their health care, CMS decides that the solution should be to merely tweak the system with more transparency while keeping it intact. The solution needed is to eliminate the restrictive provider list, allowing patient access to the entire health care delivery system.

Patients often choose their plans based primarily on the lowest premium prices. Secondarily they may sometimes check to be certain that their primary care physician is on the list, if they have one. But both of these are flawed policies. Choice of physicians and hospitals should be unlimited (except for providers expelled for reason). Also the entire health care system should be funded automatically through progressive taxes - a much more equitable system with much less wasteful administrative complexity than assigning varying individual premiums for a market of private plans.

Today CMS released the final rule on MIPS and APMs - a major administrative boondoggle if there ever was one. They just don’t get it. When we need real reform, they simply serve us more “garbage salad” (but not the one Trump serves).

PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.