Dive Brief:
- The Obama administration and state insurance regulators are developing stricter standards to address consumers' concerns. Some say health plans under the Affordable Care Act offering limited choices of hospitals and physicians have left them with unexpected medical bills. CMS, which runs the federal exchange, told the New York Times it is increasing its review of provider networks.
- According to federal officials, the new standards would be similar to provider-network adequacy standards used by CMS to oversee Medicare Advantage plans. CMS continues to refine MA network standards, looking at factors such as population density, and using maximum travel time and distance criteria.
- States may adopt additional network standards of their own; Washington did so in April. The National Association of Insurance Commissioners, representing state officials, is updating its 18-year-old model law to add new consumer protections for network adequacy. This follows actions by some insurers to try cutting costs by excluding children's hospitals, academic medical centers and cancer treatment centers from various networks.
Dive Insight:
Regulators are reacting, and offering new network adequacy standards, in the wake of widespread consumer frustration about insurers' increasingly common use of restricted providers under the Affordable Care Act. A recent class-action lawsuit brought on behalf of enrollees against Anthem Blue Cross of California reflects growing consumer push-back against these limited network plans.
Will insurers' own efforts at network expansion suffice? An official with WellPoint, Inc., Anthem's parent, told the New York Times that Anthem was working to improve the accuracy of its provider directory—and had added 3,800-plus physicians to its California exchange plans' network, a 10% increase, since January.
Insurers say plans with limited provider networks help to hold down premiums and improve quality, and surveys indicate many relatively young, healthy consumers are willing to give up broad access to providers for lower costs. Some consumers, though, complain they were misled about plans' restrictions on hospitals and doctors, and claim that "bait and switch" tactics were used.
California state regulators worry about seeing "a pattern" of consumer complains over 2014 provider networks for exchange plans. Some California plan officials said confusion in the marketplace wasn't confined to consumers: even doctors' offices didn't know what networks they were participating in.
Want to read more? You might enjoy this story on how the ultra-narrow New Hampshire network impacted excluded hospitals.