Physicians want revisions to health insurance exchange rules

HHS should allow families easier access to coverage subsidies and require insurers to provide real-time patient benefit data, doctor organizations said.

By Doug Trapp — Posted Nov. 14, 2011

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Federal health officials should ensure that families can afford health coverage, that physicians have access to patients' coverage status and type, and that physicians can lead health insurance exchanges, according to physician organization responses to several proposed rules implementing the health system reform law.

Generally, physician organizations agreed in comment letters with several proposed rules released over the summer by the Dept. of Health and Human Services, the Centers for Medicare & Medicaid Services and other agencies. The proposals address implementation of health insurance exchanges, health coverage enrollment and eligibility methods, and an insurance benefits disclosure form, among other provisions. Public comments for most of this batch of proposals were due on Oct. 31.

However, the American Medical Association, American Academy of Pediatrics and other physician organizations offered several suggestions for changes to the proposed rules. The most extensive comments referenced health insurance exchanges.

The AMA and AAP expressed concern about families not being able to secure affordable health coverage in the exchanges because of an Internal Revenue Service definition in a proposed rule addressing the premium tax credit. People earning between 100% and 400% of the federal poverty level -- $22,350 to $89,400 for a family of four -- could be eligible for a federal tax credit to offset coverage costs.

People who can buy health coverage for less than 9.5%of their incomes are not eligible for tax credits to help pay for coverage in exchanges, according to the IRS definition. But this standard does not include the cost of family coverage, wrote AMA Executive Vice President and CEO James L. Madara, MD, in an Oct. 31 letter to the IRS.

"No member of the family would be eligible for premium tax credits or cost-sharing subsidies when one member has an affordable offer of employee-only coverage," he wrote.

But Dr. Madara noted that in the proposed regulations, HHS suggested it would consider a family-based affordability test in future rules. Approximately 3.9 million dependents are in families for which coverage costs less than 9.5% of family income for the worker but not for other family members, says the Kaiser Family Foundation.

The AMA and AAP also sought to ensure that doctors could help lead exchanges. They opposed excluding physicians from serving on exchange governing boards. Some states have unduly restrictive conflict-of-interest provisions that bar doctors, Dr. Madara wrote in an Oct. 24 comment letter. "If states are concerned about a potential conflict of interest for a physician on an exchange board, then standard recusal procedures invoked at appropriate times should quell any conflict of interest concerns," he wrote.

"Omission of physicians from such boards will serve as a significant disservice to state exchanges," said AAP President Robert W. Block, MD, in a Oct. 31 letter to HHS.

The AMA emphasized the need for health plans to provide real-time, electronic verification of patients' coverage and eligibility in the exchanges. If not, doctors "could end up providing treatments that are not covered by the patient's plan, which would lead to large, unexpected bills for patients," Dr. Madara wrote. He said HHS anticipated in the proposed rule that people would transition between Medicaid and private plans based on income and plan cost.

Physician organizations supported the proposal for a standard health plan summary of benefits and disclosure form. HHS followed recommendations from the National Assn. of Insurance Commissioners Consumer Information Subgroup, which included the AMA. The insurer form would include information on out-of-pocket spending, extra costs for visiting non-network physicians and hospitals, and coverage limits. Consumers also would get a glossary of health insurance terms.

"The final product will dramatically improve consumer understandability of health care benefits," Dr. Madara wrote in an Oct. 20 letter to CMS.

The AMA and AAP also suggested that exchanges could require health plans to disclose even more data, including more details about out-of-network charges, but they expressed concern about a CMS proposal to require exchanges to be self-supporting by Jan. 1, 2015. Dr. Block said exchanges may need federal grants for technical assistance.

HHS and CMS did not predict when they would release final versions of the proposed rules.

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More specifics for health reform

The Dept. of Health and Human Services issued several proposed rules over the summer guiding implementation of the health system reform law. Public comments for five of the proposed rules were due by Oct. 31. The rules provide guidance to states and health care stakeholders on how:

  • States will create health insurance exchanges by 2014.
  • People will qualify for and enroll in plans through the exchanges and receive tax credits to help pay for the coverage.
  • People will qualify for and enroll in Medicaid through the exchanges and transition between public and private coverage.
  • Group health plans will be required to provide a benefits summary detailing coverage limits and out-of-pocket spending, plus a glossary of health insurance terms.
  • HHS and states will implement reform law provisions to help insurers transition to the new marketplace.

Source: Dept. of Health and Human Services

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