States Should Determine Provider Networks In Federal Exchanges, Health Insurers Say

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By Sara Hansard  

State determinations that health care provider networks are adequate for qualified health plans (QHPs) that will be offered in federally facilitated exchanges (FFEs) and state partnership exchanges (SPEs) should be sufficient since there is little time for further reviews before opening for enrollment Oct. 1, America's Health Insurance Plans said in a comment letter filed March 15.

AHIP's comment letter, signed by Candy Gallaher, senior vice president, AHIP state policy, was in response to a 57-page “Letter to Issuers on Federally-facilitated and State Partnership Exchanges” posted March 1 on the website of the Centers for Medicare & Medicaid Services' Center for Consumer Information and Insurance Oversight (CCIIO). Comments were due March 15.

AHIP “strongly” urged CMS to eliminate requirements for including “essential community providers” in their networks.  

Plans sold in the exchanges, which are being created under the Affordable Care Act, will take effect in 2014. FFEs and SPEs will operate in 33 states in 2014, while state-based exchanges are to be in effect in 17 states and the District of Columbia.

The letter provided QHP issuers that will be sold in the online exchange markets operational and technical guidance on how QHPs can be certified, how the agency will partner with states in regulating insurance markets, standards for plan adequacy, rate reviews, enrollment and payment procedures, and customer support.

In evaluating QHP applications, the guidance letter said that for the 2014 coverage year CMS will rely on state recommendations “when the state has the authority and means to assess issuer network adequacy. CMS's approach to reviewing network adequacy will vary based on whether the state assesses network adequacy in a sufficient manner and uses standards at least as stringent as those identified in 45 C.F.R. § 156.230(a).”

In states without network adequacy review, CMS will accept an issuer's accreditation from a accrediting entity recognized by the Department of Health and Human Services, the guidance letter said.

AHIP “strongly” urged CMS to eliminate requirements for including “essential community providers” in their networks. Some of the providers, such as black lung clinics, have not historically been organizations that health plans have contracted with, AHIP said. In addition, “major questions remain” about how the standard could be met, it said.

HHS Should Not Delegate Reviews

In its March 14 comment letter, the Center on Budget and Policy Priorities (CBPP) said that CMS should not just rely on states to take the lead in ensuring that QHPs meet standards. “Reviews for discriminatory benefit designs should not be deleted,” CBPP said in its letter, signed by Sarah Lueck and Shelby Gonzales, senior policy analysts.

“HHS must itself directly and fully ensure that QHP issuers operating in an FFE meet the requirements of section 1311(c)(1)(A) of the Affordable Care Act, which requires the HHS Secretary to ensure that qualified health plans do not employ 'benefit designs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs,'” CBPP said.

While CMS said it plans to review cost-sharing charges and “explanations” and “exclusions” information in plan documents, CBPP said the agency should also review “items and services that a QHP covers or does not cover, as well as the amount and extent of any limits on covered benefits.”

CMS should also analyze benefit limits such as visit limits, and it should review all actuarial justifications submitted to states, CBPP said.

More 'Robust' Network Adequacy Standards

CMS should establish “more robust network adequacy standards for QHPs and create a transparent monitoring system to ensure compliance and better inform consumers,” the National Health Law Program (NHeLP) said in its March 15 comment letter, signed by Executive Director Emily Spitzer. NHeLP advocates for health rights for low-income people.

Federal regulations require QHPs to maintain a network with a sufficient number of providers to assure that all services will be accessible without unreasonable delay, NHeLP noted. But it said the standard is “overly broad and will have little meaning without effective monitoring and oversight.”

The guidance letter outlined a “myriad of ways QHPs can demonstrate network adequacy,” including relying on state-level reviews as part of the licensing process, accreditation, submitting access plans as part of QHP applications, and monitoring by CMS of network adequacy through complaint tracking, NHeLP said.

“This diffuse oversight of network adequacy and lack of uniform standards and reporting will create significant challenges in effective compliance monitoring,” NHeLP said. “CMS should require all QHPs to meet and adhere to specific network adequacy standards,” including reporting primary care provider-to-enrollee ratios, provider-enrollee ratios by specialty, hours of operation, geographic accessibility, identifying providers who are not accepting new patients, and listing the waiting times for appointments with participating providers, it said. Such a system would be similar to Medicaid managed care regulations, it added.

By Sara Hansard  

AHIP's comment letter is at CCIIO's Letter to Issuers on Federally facilitated and State Partnership Exchanges is available in HealthDocs™. CBPP's comment letter is at NHeLP's comment letter is at

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