Hypothetical Network Adequacy Schemes For Children Fail To Ensure Patients' Access To In-Network Children's Hospital

Insurers are increasingly adopting narrow network strategies. Little is known about how these strategies may affect children's access to needed specialty care. We examined the percentage of pediatric specialty hospitalizations that would be beyond existing Medicare Advantage network adequacy distance requirements for adult hospital care and, as a secondary analysis, a pediatric adaptation of the Medicare Advantage requirements. We examined 748,920 hospitalizations at eighty-one children's hospitals that submitted data for the period October 2014-September 2015. Nearly half of specialty hospitalizations were outside the Medicare Advantage distance requirements. Under the pediatric adaptation, there was great variability among the hospitals, with the percent of hospitalizations beyond the distance requirements ranging from less than 1 percent to 35 percent. Instead of, or in addition to, time and distance standards, policy makers may need to consider more nuanced network definitions, including functional capabilities of the pediatric care network or clear exception policies for essential specialty care services.