Regulators are polishing an addition to the standards state examiners use to verify insurer compliance with the Patient Protection and Affordable Care Act (PPACA) and other laws.
Examiners will use the new section to see if insurers are giving plan enrollees the required level of access to health care providers.
Members of the Market Conduct Examination Standards Working Group at the National Association of Insurance Commissioners (NAIC) have posted a draft of the section. Comments on the section are due Dec. 31.
See also: Regulators draft PPACA complaint codes
The draft section would affect PPACA-compliant plans that use primary care doctors to manage access to specialty care.
If a plan uses a primary care doctor as a gatekeeper, PPACA requires the plan to let a family use a pediatrician as the gatekeeper doctor for a child.
PPACA also requires a plan with a primary care gatekeeper to let women get obstetric and gynecological (ob/gyn) care without first getting referrals from primary care doctors.
The drafters have described the documents that an examiner should review, such as training materials, complaint logs and internal grievance files. The drafters have also described the procedures and criteria examiners should use when reviewing the materials.
The criteria sections include examiner notes. The drafters state in one, for example, that a health carrier can require an ob/gyn care provider to respect policy coverage exclusions and to tell the primary care doctor about treatment decisions.