On the heels of massive network terminations made across the country for the 2014 health plan year that caused enormous confusion for patients and their physicians, the Centers for Medicare & Medicaid Services (CMS) and many states are considering ways to ensure health plan networks provide sufficient access to care. Physicians are at the forefront of these efforts, standing up for patient needs.
Medicare Advantage: Progress for 2015, future changes possible
The move to narrow networks for Medicare Advantage plans made headlines late last year as thousands of physicians were terminated without cause by UnitedHealthcare, even as seniors were required to choose their coverage during open enrollment.
The terminations caused serious disruption to longstanding patient-physician relationships, physician referral networks and emergency department coverage. Physicians led the charge in calling on CMS to act, and in one state, they succeeded in having a court intervene.
In March, the AMA submitted comments to CMS regarding its requirements of Medicare Advantage carriers for the 2015 health plan year. The agency acted on a number of AMA recommendations that should ensure a much-improved situation for physicians and patients next year.
Carriers will be required to notify CMS at least 90 days before “significant” network changes so the agency can evaluate these changes prior to execution. Although the agency did not establish a numerical definition of “significant” in its requirements (the AMA had suggested anything exceeding 10 percent would be significant), CMS made it clear that it expects carriers to err on the side of caution.
“We intend to take appropriate compliance action against a Medicare Advantage organization that fails to notify CMS of network changes that we ultimately deem significant,” the agency stated in its April 7 letter to carriers. “Therefore, we expect Medicare Advantage organizations to take a conservative approach in determining whether a network change is significant and notify CMS if there is any doubt as to whether the planned contract termination(s) represent significant change to the network.”
Consistent with AMA recommendations, CMS also is asking health insurers to provide more notice to patients and physicians. For now, Medicare Advantage plans will continue to be required to give patients at least 30 days’ notice if their physician is to be terminated from the network, while physicians should receive at least 60 days’ notice. The agency has made it clear, however, that requirements for longer notice remain under consideration. CMS is encouraging insurers to give more than the required minimum as a “best practice.”
Health plans on the ACA exchanges: More active review
For health plans being sold on the Affordable Care Act (ACA) health insurance exchanges, CMS said it will take a more active approach to requiring network adequacy.
In comments submitted in February, the AMA called for greater oversight of these plans, stating that the existing regulations are “too vague, leave too much discretion to insurers to determine network adequacy and need to be strengthened in future rulemaking.”
CMS’ final letter to issuers in federally facilitated exchanges stated that the agency would use a “reasonable access” standard for evaluating plans for 2015. CMS intends to review plans’ lists of physicians and other providers as one way to determine adequacy.
In addition, “CMS will share its network adequacy findings with states and will incorporate state input into its network adequacy review process. CMS will also continue to monitor network adequacy, for example, via complaint tracking, to determine whether the qualified health plan’s network(s) continues to meet these certification standards.”
Action in the states
In addition to federal regulations, many states are taking up the issue of narrow networks. One recent development could help ensure those actions are productive.
The National Association of Insurance Commissioners in March responded to the AMA’s call for the group to revise its model bill on network adequacy. The group now is working with the AMA and others, including payers, on a new version that should address current trends.
As the nation continues to explore ways to expand access to care at an affordable cost, the AMA will remain engaged to broaden restrictively narrow networks so patients have access to the care they need from the physicians they trust. Read more in AMA Wire™ about specific efforts taking shape in the states.
