ACA multistate plans must not fly under regulatory radar, AMA says

The Association is concerned that insurers might be granted too much latitude in complying with state and federal consumer protection requirements.

By — Posted Jan. 29, 2013

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

To protect physicians and patients, multistate plans offered on upcoming health insurance exchanges should be held to the same regulatory standards as other private insurance offerings, the American Medical Association wrote in a Jan. 4 comment letter to the U.S. Office of Personnel Management.

The Multi-State Plan program was established by the Affordable Care Act to promote competition and encourage the availability of high-quality, affordable products in the insurance exchange marketplaces.

At least two multistate plans, one of which should be from a nonprofit insurer, must be offered on the exchanges starting in 2014. Such plans would be able to offer insurance to small businesses that operate in — or families that reside in — more than one state. In November 2012, the Office of Personnel Management issued a proposed rule establishing standards for these multistate plans and sought public comment from stakeholders.

In the AMA’s letter, Executive Vice President and CEO James L. Madara, MD, wrote that the Association had high hopes for the exchanges but that “all insurance participants need to be playing by the same rules to prevent adverse selection and competitive advantages.”

Need for healthy competition

The multistate plans will serve as an important tool to foster healthy competition in the health insurance marketplaces, Dr. Madara wrote. However, the AMA has concerns that the rule offers too much latitude to the multistate plans when it comes to complying with state and federal consumer protection requirements, he stated.

As an example, the Office of Personnel Management’s criteria for establishing adequate networks of contracted physicians and other health care professionals for these plans is too broad “and leaves too much discretion to OPM to determine the adequacy of a provider network,” Dr. Madara wrote. An inadequate network could force patients to reduce their use of preventive services and other necessary care, resulting in avoidable illnesses, increased use of emergency departments, work absences and lost productivity, he said.

The AMA recommends that all multistate plans comply with state network adequacy mandates as well as the consumer protection laws in the state where the enrollee lives. State insurance departments also should certify the networks of these plans, Dr. Madara wrote. In the meantime, the Association will share its own model legislation on network adequacy with states to help them strengthen their requirements.

The rule’s provisions on medical-loss ratios — which require insurers to spend a certain percentage of premium dollars on medical care — also may create an unlevel playing field between multistate and other plans, according to Dr. Madara’s comment letter. The Office of Personnel Management is reserving the authority to assign an entirely different minimum threshold to these plans if it deems that the change would benefit enrollees. But having multistate plans operate under their own requirements in this area would undermine the health system reform law’s transparency goals for insurers, Dr. Madara wrote.

The AMA urges that the Office of Personnel Management retain the final medical-loss ratio requirements that the Dept. of Health and Human Services adopted for the health insurance exchanges, which already have saved patients billions of dollars, “and not allow any flexibility or reduced patient protections for multistate plans,” the letter stated.

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn