APA and MPS Advocate for Network Adequacy


On February 11, 2015, the APA and the MPS sent a letter (Letter to MD Gov and Insurance Comm re Parity w Attachments) to Governor Hogan and MIA Commissioner Redmer bringing attention to the very serious problem of access to mental health care, and in particular to psychiatrists, in Maryland’s 2014 Qualified Health Plans (“QHPs”) sold through Maryland Health Connection.  It also highlighted the general need to ensure that all health plans meet network adequacy standards.  The current situation results in higher health care costs for Marylanders and patients with untreated mental illnesses. Excerpts from the letter follow:

On January 26, 2015, the Mental Health Association of Maryland published “Access to Psychiatrists in 2014 Qualified Health Plans,” which chronicles a study of the adequacy of the psychiatric networks in Maryland’s four QHPs examining the accuracy of the provider directories and availability of the 1,154 psychiatrists in those directories to see patients within 45 days. The study results are devastating to those with mental illness or substance use disorders.  Specifically,

  • only 43% of the psychiatrists listed could be reached primarily because phone numbers were not working or incorrect, or the physician died, retired or relocated. (page 5)
  • 19% of those who were reached were not actually psychiatrists although they were listed as such. {page 5)
  • Less than 40% of the providers listed accepted the insurance of the company listing them as a participating provider. (page 6)
  • Less than 18% of the psychiatrists listed were taking new outpatients. (page 6)
  • Only 14% of psychiatrists listed and taking on new patients could see the patient in less than 45 days. (page 1)

Health plans have ready access to the claims data to know whether a physician is taking new patients and whether the physician is an active participant in the plan, but there is no evidence that they use their data to assure their network is sufficient to meet the consumer’s needs. Plans can and should run the data on claims filed for each physician listed in their network on a quarterly basis. If a listed physician has not filed a claim in the past quarter, the physician obviously is not taking that insurance. Likewise, a small volume of claims should lead the carrier to question whether the physician is an active participant in the network and fairly included in the carrier’s analysis of network adequacy. For plans that have an out of network benefit, the plan should run out of network claims data; a large volume of out of network claims means there are not sufficient choices in network because most patients would not voluntarily choose to pay out of pocket if the network in the plan was sufficient.

As you know, the state has the authority to require plans to verify the adequacy of their network and plans have the means to do it. APA respectfully requests that you require all exchange plans (indeed we recommend the state should require all insurance plans) on a quarterly basis to verify the adequacy of their network by publicly reporting (a) the number of claims filed by each psychiatrist listed in the network; and (b) publicly reporting the number of psychiatric claims paid on an out of network basis. Plans must then be required to update the network directories and their network adequacy analysis to remove those physicians that are not actively participating.

Appropriate treatment of mental health conditions will ensure overall health of the population and it will decrease the overall cost of medical care. As evidenced in the attached study by Milliman, spending on mental health care actually reduces the overall cost of health care for individuals and for the state.

Accordingly, APA asks that the state of Maryland ensure that: (a) citizens of the state get access to the mental health care for which they have paid, and (b) health insurance carriers are responsible for providing the resources promised to their customers.  APA would like to work with the state of Maryland to make mental health care, an essential health benefit, available to all of its citizens.