2017 ACA Applicants and Network Transparency

The National Association of Insurance Commissioners (NAIC) completed their review of provider network rules and published a draft of a new Model Rule. This is the first update of network rules in over 20 years. NAIC convened a committee of regulators, health plans, and consumers to provide input to the development of the draft document. The drive to develop the new rules came from the realization narrow networks used in Marketplace plans were the basis of increases in consumer complaints. Throughout the draft, NAIC recognizes the differences that exist between regulations in various states and the proposed changes, so any state can choose to follow the draft or construct its own rules. It has a three-year timeline.

At the same time in December, the Centers for Medicare & Medicaid Services (CMS) proposed network regulations for Qualified Health Plans (QHPs). The final regulation published in February, however, recognized the three-year NAIC timeline, sort of.

First, the draft NAIC rule takes on some of the changes prompted by the Affordable Care Act (ACA) in several ways. NAIC revises definitions for emergency services and conditions, emergency service stabilization, primary care and specialty providers, telehealth, as well as tiered networks. With new definitions throughout the document, the impact of the changes becomes more evident. Draft NAIC rules incorporate final ACA rules that specify in greater detail what health plans must do when they fail to have a provider for a covered benefit. These include payment, notice to persons who need the benefit, and a process for requesting services from a non-participating provider.

Second, the most significant section discusses network adequacy. This section adds many of the ACA requirements related to underserved individuals, children, tiered networks, as well as access. Alternatively, it also recognizes some states use time, distance, and waiting standards. To avoid potential state/federal conflicts, CMS proposed new network rules that would have required CMS to approve state network rules. If CMS did not approve the state method, a federal default based on time and distance would have applied. CMS decided not to finalize this rule, stating they would monitor the states’ adoption of the NAIC standard over a three-year period before making any new federal regulation. But, in the end, CMS said they would still apply time and distance standards anyway. It’s likely this will be the case for the foreseeable future — not just 2017.

So, what will be the effect of this new model rule? First, nothing defines “without unreasonable delay.” Notably, over the past three years, CMS has cited this same regulatory language as frustrated applicants sought to fix networks CMS rejected. The CMS approach to unreasonable delay appeared to be “we’ll know it when we see it.”

In an attempt at transparency, CMS has finally provided a set of time and distance metrics. Notably, for many years in Medicare, CMS has used software based on time and distance standards and, no doubt, has been using it for QHPs. The magic of the software is it provides a view of what CMS may see in an applicant’s network. Using software quickly provides targets and assists in developing justifications needed to address gaps. GHG conducts network access reviews using this same software to ensure QHPs meet access rules before submission to CMS. So, with increasing pressure to build narrow networks, QHPs can have access to solid support tools on what meets access without unreasonable delay.

Resources

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The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one.  Completing the application requires the cooperation from your entire organization.Don’t let the application process get in the way of your day-to-day operations.  Contact us today to ensure a smooth, compliant process.

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