AMA pushes for better insurance exchange networks

The Association compiles a list of what information regulators and consumers must have about the coverage networks offered under the ACA.

By — Posted March 29, 2013

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Standards ensuring that consumers have access to sufficient networks of health care professionals on federally operated health insurance exchanges need to be tightened, the American Medical Association wrote in a March 15 letter to the Obama administration.

In his correspondence to acting Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner, AMA Executive Vice President and CEO James L. Madara, MD, specified what information qualified health plans on these marketplaces should be providing. Insurance regulators and consumers need to be able to make informed decisions on whether a plan’s network has an adequate supply of primary care and specialty physicians, he stated.

Dr. Madara was responding to guidance CMS issued March 1 to insurance companies that will be offering qualified health plans in federally facilitated or partnership health insurance exchanges. These are the companies CMS will be working with, as both the federal and partnership models involve a central administrative role for the federal government. States pursuing partnership exchanges will retain some traditional state insurance roles while receiving federal structural and financial support to run the marketplaces.

More than half of the states are set to default to the federally facilitated model, and seven states have chosen to partner with the federal government on an exchange. Seventeen states and the District of Columbia are pursuing state-run marketplaces. The agency expects that any state, regardless of whether it or the federal government operates the exchange, may use the March 1 letter to issuers of qualified health plans as guidelines in developing their own procedural operations.

Final regulations specified that qualified health plans must offer adequate networks of physicians and other health care professionals, including mental health and substance abuse professionals, to ensure that consumers will be able to access all needed health care services without unreasonable delays. But in the AMA’s view, these standards are too vague, making it difficult to gauge whether the qualified plans are meeting them.

Sick, costly patients may be forced out

Without adequate networks, consumers might not seek out preventive services or might avoid obtaining needed medical care, the AMA stated. A potential result of this is that the sickest patients in the least adequate networks will end up getting driven out of the system, leaving the health insurance plans with the least risky patients, Dr. Madara wrote. Consumers, as well as regulators, “need meaningful measures of network adequacy covering all aspects of the network, including emergency and other hospital-based physicians, taking into account any tiering or other network restrictions.”

To ensure that consumers’ expectations are met in these exchanges, health insurance benefits should be available to them “at the preferred, in-network rate on a timely and geographically accessible basis,” the AMA letter stated. Insurance regulators and consumers also should have access to certain pieces of information to determine the adequacy of qualified health plans’ networks. An example of this are the requirements health plans must meet for network quality assurance processes, or “definitions to ensure that the adequacy of the entire provider network is evaluated,” the letter stated.

Dr. Madara also emphasized the need for objective data on critical access measures, such as the number of visits made to out-of-network health care professionals per 1,000 enrollees, or what percentage of services from in-network physicians and other professionals are making up the percentage of total services enrollees received.

The suggestions were based on the AMA’s model bill on how health insurance issuers could develop adequate networks of health professionals. In the letter, Dr. Madara urged CMS and the states to use the Association’s model as a guide for determining network adequacy.

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