Feb. 5—Insurance plans sold next year in government-run marketplaces may need to include more providers than existing plans, according to changes proposed this week by the Obama administration.

The draft version of an annual letter from the Centers for Medicare & Medicaid Services (CMS) to insurers offering plans in the marketplaces, or exchanges, created by the Affordable Care Acre (ACA) to sell individual and small group insurance spelled out changes under consideration for 2015.

Among the proposed changes for marketplace plans were several provisions aimed at narrow provider networks.

“In 2014, CMS largely relied on plan accreditation and state review to ensure adequate provider networks,” Tim Jost an expert and supporter of the 2010 healthcare overhaul, wrote in a Health Affairs blog post. “One of the biggest complaints so far about QHP plans, however, has been that provider networks have been too narrow.”

The 2015 proposed changes include CMS collecting plan provider lists and reviewing them to determine whether providers are available without unreasonable delay (likely based on time and distance standards). The reviews would focus on access to hospital systems, mental health providers, oncology providers, and primary care providers.

Another proposed change that may ease customer shopping for a new plan would require plans to post their provider directories online and open to the public. That change could address the concern raised by some applicants that they were uncertain whether their physician or preferred hospital was included in the networks of plans they were considering buying.

Another change involves essential community providers (ECPs), which all plans were required to include. Many safety net hospitals and other providers that serve higher proportions of low-income patients and are categorized as ECPs complained plan networks excluded them—essentially making access to their care unaffordable for the newly insured.

The new requirements proposed increasing the share of such providers that plans must include in their networks from 20 percent of ECPs in the service area to 30 percent of ECPs. Additionally, plans would need to include at least one ECP in each ECP category. Marketplace plans, known as QHPs, unable to meet the 30 percent threshold could offer an explanation of their unsuccessful efforts to get the requirement waived.

“The Letter strongly suggests that CMS is expecting QHPs to improve access to ECPs,” Jost wrote.

Such changes came in response to widespread news reports of limited networks dominating marketplace plans. Among the small number of studies of the phenomenon was a December 2013 review by McKinsey & Company that found 0 percent of 120 plans examined from 80 insurers had “narrow and ultra-narrow hospital networks.”  The narrow networks that some insurers employed to keep their plan costs low drew threats of lawsuits and legislation in several states.

Other proposed changes would address concerns that plans have higher out-of-pocket costs than traditionally included in employer-sponsored plans. For instance, CMS plans to review insurance policies with an unusually large number of drugs subject to step therapy or prior authorization.

Other changes under consideration by CMS include requiring all plans to allow three primary care office visits prior to meeting any deductible. Such changes may aim to assure lower income ACA beneficiaries that they can access services without having to first pay deductibles that may be thousands of dollars, according to health policy experts.

Marketplace plans for 2015 coverage will be reviewed for compliance with the new federal standards over the summer and plans must be finalized by Oct. 17. Open enrollment starts Nov. 15. 


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare.

Publication Date: Wednesday, February 05, 2014