The people picked to represent consumers in National Association of Insurance Commissioners (NAIC) proceedings are asking regulators to make sure health insurers offer enough doctors, hospitals and other health care providers to serve enrollees’ needs.
When enrollees have trouble getting timely care from in-network providers, insurers should be prepared to negotiate with the out-of-network providers themselves and limit the enrollees’ out-of-pocket costs to the costs that would be required for comparable care obtained in-network, the consumer reps say.
The consumer reps express their concerns in a comment letter posted on the website of the NAIC’s Exchanges Subgroup.
The NAIC, Kansas City, Mo., provides representatives from patient groups, groups that say they speak for consumers, and other individuals who agree to represent consumers in NAIC proceedings with stipends.
The Exchanges Subgroup has been holding telephone conference calls on the issue of network adequacy and has been drafting a paper on the topic.
The subgroup is developing the paper to help states that are thinking about how they will ensure that carriers offer adequate provider networks once the Patient Protection and Affordable Care Act of 2010 (PPACA) takes effect. PPACA provisions require state and federal agencies work to set up a system of health insurance exchanges, or Web-based insurance supermarkets, and states may need want to think about strategies for ensuring compliance with network adequacy requirements both inside the exchange system and outside the exchange system, paper drafters say in the current draft.
Insurers form provider networks by negotiating directly with providers and by renting networks from other organizations. Advocates of the provider network approach say forming contractual relationships with the providers in the networks gives them the ability to apply quality standards and bargain for lower rates.