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PPACA: NAIC Panel Eyes Network Adequacy

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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.

Some insurers have broad networks at all levels. Others limit the number of specialists, or limit the number of all types of providers in the network, in an effort to get the very lowest possible rates in exchange for sending the providers in the narrow networks a large number of patients.

The consumer reps say in a comment letter that the provider network offered by a health plan is a key attribute of the plan’s coverage.

“However, many aspects of that network are not transparent to the consumer today,” the reps say. “In addition, many states lack minimum thresholds with respect to network depth and breadth – a necessary precondition for coverage to be meaningful.”

In extra material added recently to the latest version of the network adequacy paper, drafters say that, when a plan gives patients financial incentives to see preferred providers, “a sufficient number of the preferred providers must be made available in a given service area.”

“Failure to provide a sufficient number of providers results in an illusory benefit and may be grounds for form disapproval or unfair trade practice violations due to false and misleading advertising in the sale of a product,” the paper drafters say.

State insurance regulators need a process to determine whether a plan offers adequate access to all providers and facilities in its service area without unreasonable delay or the need for enrollees to travel an unreasonable distance, the drafters say.

Networks should include radiologists, pathologists and emergency room physicians, not just the hospitals where those physicians practice, the drafters say.


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