States prod­ded on net­work rules

Modern Healthcare - - NEWS - By Bob Her­man

State health in­sur­ance of­fi­cials and in­dus­try stake­hold­ers are on the brink of ap­prov­ing model leg­is­la­tion to stan­dard­ize the net­work ad­e­quacy of health plans. But the fate of that leg­is­la­tion hangs on the pri­or­i­ties of 50 very dif­fer­ent state leg­is­la­tures.

The Na­tional As­so­ci­a­tion of In­sur­ance Com­mis­sion­ers has been work­ing on up­dates to its Health Ben­e­fit Plan Net­work Ac­cess and Ad­e­quacy Model Act for more than a year. That doc­u­ment, which hasn’t changed much since its in­cep­tion in 1996, func­tions as a tem­plate for states to fol­low. NAIC mem­bers will vote on the fi­nal draft at their na­tional meet­ing on Nov. 22.

In­sid­ers be­lieve states with lax or nonex­is­tent guide­lines will use the NAIC model to craft their own leg­is­la­tion when they re­con­vene next year, whether their state is run by supporters or op­po­nents of the Af­ford­able Care Act. The CMS is also ex­pected to fol­low the model NAIC frame­work for its 2017 pro­posed health plan ben­e­fit rule, which is ex­pected later this month.

“I’ve heard that states ... take th­ese NAIC model leg­is­la­tion pieces very se­ri­ously, even states that have lots of dif­fer­ences po­lit­i­cally,” said Kather­ine Hemp­stead, health in­sur­ance di­rec­tor at the Robert Wood John­son Foun­da­tion.

“This isn’t really a par­ti­san is­sue,” said Claire McAn­drew, pri­vate in­sur­ance pro­gram di­rec­tor for the pro-ACA group Fam­i­lies USA, adding that vot­ers are urg­ing ac­tion on the leg­is­la­tion.

The NAIC be­gan ex­am­in­ing its net­work ad­e­quacy guidance last year when nar­row net­works be­came com­mon­place as a way to make plans more af­ford­able. Nar­row net­works limit the num­ber of providers avail­able to their mem­bers at in-net­work rates. Mem­bers who want a broader se­lec­tion of providers must pay more to use them.

But nar­row net­works also have con­fused pa­tients and lim­ited ac­cess to nec­es­sary spe­cial­ties. In some cases, the net­works have led to ex­or­bi­tant out-of-pocket ex­penses. Bal­ance billing, in which out-of-net­work providers charge pa­tients for what­ever their health plans don’t cover, is a bud­ding na­tional is­sue. It’s es­pe­cially prob­lem­atic when pa­tients see physi- cians at an in-net­work fa­cil­ity, but are un­aware that the physi­cians them­selves are out-of-net­work.

The ACA set some fed­eral re­quire­ments for net­works, al­though they are left up to in­ter­pre­ta­tion. All health plans sold on the ex­changes must have suf­fi­cient and di­verse providers “to as­sure that all ser­vices will be ac­ces­si­ble with­out un­rea­son­able de­lay.” ACA­com­pli­ant plans must in­clude at least 30% of es­sen­tial providers in their net­works and up­date their provider di­rec­to­ries monthly. But the ACA did noth­ing to ban or limit bal­ance billing.

Cor­rect­ing and up­dat­ing plan in­for­ma­tion has been the low­est-hang­ing fruit for states, some of which have taken ac­tion. This month, Cal­i­for­nia fined Blue Shield of Cal­i­for­nia and An­them Blue Cross for mis­lead­ing con­sumers with er­ror-laden provider di­rec­to­ries.

“Their net­works are tighter and more in­ten­tional now,” Hemp­stead said of in­sur­ers in gen­eral. And that “puts more re­spon­si­bil­ity on the car­rier to say, ‘Yes, I do know who’s in my net­work.’ ”

Twenty-seven states, in­clud­ing Cal­i­for­nia and New York, al­ready have net­work rules in place that are stricter than the fed­eral guide­lines, ac­cord­ing to Jeremy Earl, a health­care at­tor­ney at McDer­mott Will & Emery. They have quan­ti­ta­tive, mea­sur­able stan­dards such as max­i­mum travel times or dis­tances to a cer­tain provider. Oth­ers have max­i­mum ap­point­ment wait times or provider-to-en­rollee ra­tios.

The NAIC draft does not man­date those types of cri­te­ria, in­stead leav­ing them up to state in­sur­ance reg­u­la­tors. It’s ex­pected con­sumer ad­vo­cates will push reg­u­la­tors to adopt them.

“It’s un­der­stand­able that the stan­dards would be dif­fer­ent, but we still think a stan­dard should be in place,” McAn­drew said.

Other ma­jor com­po­nents of the NAIC model law in­clude a process for bal­ance billing and tiered-net­work jus­ti­fi­ca­tion. In both emer­gency and non-emer­gency sit­u­a­tions, the NAIC rec­om­mends hold­ing pa­tients harm­less for un­ex­pected bills. In­stead, in­sur­ers and providers could work out terms through ar­bi­tra­tion. New York en­acted a sim­i­lar process this year. In­sur­ers must also ex­plain the cri­te­ria for tiered providers. Providers who don’t get into pre­ferred tiers say they don’t know how those de­ci­sions are made, Earl said.

It’s un­clear how many states will fully adopt the NAIC pro­pos­als, said Richard Cauchi, health pro­gram di­rec­tor at the Na­tional Con­fer­ence of State Leg­is­la­tures. Forty-six state leg­is­la­tures will be back in ses­sion early next year, and some states could act quickly. Leg­is­la­tors in Colorado, for in­stance, meet for only 120 days, so their work is usu­ally wrapped up by May. But Mon­tana, Ne­vada, North Dakota and Texas state law­mak­ers will not con­vene in 2016.

The states most likely to act quickly will be those field­ing pub­lic in­put, McAn­drew of Fam­i­lies USA said. Florida and Penn­syl­va­nia, both large swing states, have hosted fo­rums on net­work ad­e­quacy and sur­prise med­i­cal bills.

Eileen Bourey, a Penn­syl­va­nia res­i­dent, par­tic­i­pated in her state’s hear­ing last month. She said her son An­drew sought treat­ment for his in­jured an­kle ear­lier this year, and he re­ceived more than $1,000 in un­ex­pected bills even though he thought his care was within his in­sur­ance net­work.

“This is un­de­served hard­ship for cit­i­zens who are try­ing to ask the cor­rect ques­tions up­front,” she said in writ­ten tes­ti­mony.

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