Federal health insurance officials and the National Association of Insurance Commissioners (NAIC) have recently issued proposals to protect patients when a doctor or hospital leaves their health plan’s network. As insurers in the Affordable Care Act (ACA) marketplaces have shifted toward narrower provider networks, policymakers have recognized that consumers, particularly those in the midst of a course of treatment or during a pregnancy, should have peace of mind that they’ll be able to maintain their relationship with their provider without undue financial hardship.
These issues are not new, however. Many states enacted continuity of care protections in the 1990s, as insurers shifted from broad provider networks to HMO-style closed networks. The proposed new federal rules and the NAIC’s model state law are both grounded in these longstanding state laws, although the scope and strength of the states’ continuity of care protections vary widely.
What’s in the Federal Proposal?
The federal proposal applies to plans offered through the federally facilitated marketplace and attempts to prevent disruptions in care for patients by allowing them to continue seeing their provider with in-network cost-sharing for a period of time after the provider has left the network.1 It extends this protection to patients in an “active course of treatment” for up to 90 days, or whenever the patient’s treatment is complete, whichever is sooner. The proposal defines an active course of treatment as including, for example, care for an acute or life-threatening condition or the second or third trimester of pregnancy. The proposal also requires insurers to provide advance notice to patients when a provider is being terminated from the network. Unlike the NAIC model law and many state laws, however, the federal rule does not limit the continuity of care protection to the patients of those providers that agree to accept the plan’s in-network payment rates. In other words, under many state laws, for enrollees to take advantage of this protection, their doctor or hospital must agree to continue to accept the plan’s reimbursement rates and meet other contractual requirements, such as a requirement to report quality data.
Longstanding State Laws Vary
Our preliminary review of state laws finds that 45 states have enacted a requirement that insurers provide continuity of care for enrollees. Of those, 19 states have more expansive protections than the federal proposal, in that the protection also applies when a consumer switches to a new insurance carrier with a different provider network.
State laws also place some boundaries around the continuity of care protection. Thirty states limit access to continuity of care to patients of those providers that agree to accept the terms and conditions required by the plan.
Consumers have difficulty taking advantage of a protection if they don’t know about it, so like the federal rule and NAIC model act, 30 of the 45 states with continuity of care protections require insurers to notify members when a provider will be terminated from the network, usually within 30 days. Such notices give consumers—and their caregivers and providers—time to research new provider options and help prevent potential gaps in care.
A Minimum Standard for Consumer Protections
Comments are due on the proposed federal rule by December 21, 2015. The diversity among the state rules affecting who can take advantage of continuity of care protections and under what circumstances suggests that setting a federal minimum standard of protection will be important. In determining the final federal policy on continuity of care, regulators should examine the experience of states with longstanding requirements, including those that have more robust protections than outlined in the federal proposal.
In particular, the federal proposal could go further by extending the protection to consumers who change plans, which is currently available in 19 states. Some insurers may have concerns that these type of requirements force them to enter into relationships with providers that charge too much or do not meet their quality standards. At the state level, however, this protection is often limited to the patients of providers who agree to accept the plan’s rates and contract terms.
Some assurance of continuity of care could be particularly important for consumers enrolled in plans through the health insurance marketplaces. For these enrollees, marketplace officials have repeatedly urged them to return to the marketplace to compare and shop for a new plan to ensure they can maximize the value of their premium subsidy. In other cases, enrollees have no choice but to switch plans because their insurer has left the marketplace or discontinued the plan they were in. Either way, changing plans often also means changing provider networks. For consumers in the midst of a course of treatment, they deserve to have peace of mind that if they do so, it won’t disrupt their care.
1Federal regulators request comment on whether the continuity of care protections should be extended to plans sold through the state-based marketplaces.