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More skirmishes from the provider network war

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State regulators are working on model law revisions that could have a big effect on which doctors, hospitals and other providers are in your health insurance customers’ provider networks.

Members of the Network Adequacy Model Review Subgroup, part of the National Association of Insurance Commissioners (NAIC), have just released a draft of the proposed revisions that is full of red ink. The red ink shows that revisions regulators could make in the existing model. 

The subgroup is preparing to talk about the draft at a session Monday.

Some health insurers, provider network management companies and policymakers have argued that flexibility in network design is one way for an insurer to hold the cost of a plan down without restricting access to benefits. Critics say some plan enrollees, especially those who are using the new Patient Protection and Affordable Care Act (PPACA) public exchange system, may end up plans based solely on the monthly premiums without understanding how limited their access to doctors and hospitals might be.

How could some of the proposed changes affect your customers? Read on.

The revised model could:

  • Add a formal definition of “balance billing” — the practice of an out-of-network provider billing for the difference between the provider’s stated charge and the health plan issuer’s allowed amount.
  • Add a definition of “emergency medical condition” that would include symptoms that would “lead a prudent layperson, possessing an average knowledge of medicine and health” to expect to suffer harms such as serious impairment of bodily functions, serious impairment of a bodily functions, or a threat to the safety of an unborn child.
  • Add definitions of “telemedicine” and “ telehealth.”
  • Expand the situations in which a plan would have to make out-of-network care available at in-network rates.
  • Give enrollees who are undergoing “active treatment” the treat to continue to see their old providers when a health plan issuer terminates the providers’ contracts without cause.
  • Set minimum provider directory standards, including standards for online directories.
  • Increase the number of situations in which a plan issuer would have to tell regulators about network changes. In a drafting note, drafters have suggested that regulators might want to get warnings from issuers when material changes in provider reimbursement rates and enrollees’ out-of-pocket costs might affect the enrollees’ access to providers.

See also: 3 ways proposed PPACA risk program rules could trip you up


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