Some providers believe the tool has limited use and may confuse consumers.


Aug. 25—A previously announced national tool to determine provider network breadth in Healthcare.gov plans will be downsized, a recent Centers for Medicare & Medicaid Services (CMS) bulletin announced.

The tool, which earlier this year was predicted to be available nationally, only will be offered in a pilot program in six states during the 2017 open enrollment period, an Aug. 19 CMS bulletin CMS said. The tool will allow consumers to make meaningful comparisons about the size of provider networks on Healthcare.gov when selecting qualified health plans.

In the bulletin, CMS did not explain why the program would not be available nationally and a CMS spokesman did not respond to questions about the change in decision.

The bulletin explained that “the goal of the network breadth pilot is to help CMS understand how consumers make use of the network breadth information.”

In March, CMS published a final rule that provided greater transparency about the breadth of provider networks at the county level to patients choosing plans on Healthcare.gov, including the methodology used in determining network breadth ratings.

A CMS spokesperson said the pilot states under consideration were selected to provide a cross-section of plans with different network availability and where states perform plan management functions, among the 37 federally operated marketplaces. CMS plans to apply what it’s learned from the 2017 pilot to gauge whether the pilot will be replicated and expanded to additional states or provider types in future years. 

In the yet-to-be-named six states, the tool will allow consumers to compare networks for three provider types: adult primary care providers, pediatricians, and hospitals. Health plan provider networks are rated by provider participation: Standard for an average size network; Broad for a larger than average network; and Basic for a narrow network of providers.

Market Impact

David Kopans, a healthcare attorney at Jones Day, said “everyone will be watching those six states to see how this tool will impact consumer selection of plans and whether it will be a determining factor. I think we’re in a ‘wait and see’ period to see how this impacts consumers.”

Kopans said this is the third CMS document on provider network breadth transparency, starting with a February 2016 letter to insurers, a March listing on the Federal Register and the recent bulletin.

He said the tool will give consumers a signal about the size of provider networks in the plans operating in their counties, but noted it does not rate plans on quality or cost.

“It’s giving more information for the consumer,” he said. “It may work well or the consumer might ignore it and just choose plans by the cost of premiums.”

Because the tool only rates plans by provider participation, some consumers may feel misled, Kopans said.

“Some hospitals may create a really high quality network with a payer in their area, but it could be rated ‘Basic,’ which may send the wrong signal,” Kopans said. “Consumers may choose a ‘Broad’ network that excludes the only children’s hospital in the area—which they need---but includes everyone else.”

The provider network breadth rating revives the old debate about the advantages of PPOs versus HMOs, narrow, quality curated restrictive networks or wide networks that offer more choices, Kopans said.

“The question is will people understand the distinctions? Narrow networks have negotiated lower provider rates and pay providers less, which should translate to lower consumer costs and higher quality, while broader networks historically have less rate leverage and control over quality than narrow networks and in theory charge larger premiums for greater choice,” Kopans said. “But how much will consumers learn simply by the size of the provider networks?”

Why a Pilot?

CMS releasing the tool as a pilot suggests the agency is being cautious and probably doesn’t want to cause market disruption just to increase plan transparency, Kopans said.

“CMS choosing to release this is as a pilot is the least controversial aspect of this program. Providers have expressed far greater concerns about having those network size designations.”

Molly Smith, senior associate director of policy development for the American Hospital Association (AHA), said the AHA was disappointed by the announcement that only six states would offer the tool.

“It’s really important that consumers understand the types of plans and coverage they are buying and have easy access to knowing which providers are in-network,” Smith said.

Hospitals are concerned about the difference between what’s considered narrow and what’s broad, Smith said.

“Most consumers don’t understand this and sometimes find out too late,” she said. “It’s not entirely surprising, because everything about provider networks is more complicated than it seems. But we hope that CMS will make this tool available in every community.”

Consumers need a tool to determine whether or not their hospitals are in network, Smith said.

She speculated that some bigger teaching hospitals with strong brands and long traditions of high quality that may have higher costs due to the severity of the cases they treat or the teaching and research they do may be excluded from some networks based solely on cost.

“It’s often surprising to consumers when they want to access care from those providers, they realize they’re not in network,” she said. “So any tools that would shed a light on that sooner would raise questions of insurers about why those providers are not in network.”

Molly Collins, policy director for AHA, said the provider network breadth tool is one way of creating greater transparency around provider networks.

“That could go a long way towards addressing concerns about surprise bills patients receive from providers they assumed were in network,” Collins said.

She noted that AHA is working with the National Association of Insurance Commissioners to define and clarify what constitutes adequate provider networks, as well as a process for resolving ‘surprise bills’ that places responsibility on physicians and health plans.


Mark Taylor is a freelance writer based in Chicago.

Publication Date: Thursday, August 25, 2016