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Insurance Commissioners Hope to Stave Off Tough Federal Oversight of Plan Networks

By Rebecca Adams, CQ HealthBeat Associate Editor

September 26, 2014 -- The nation's health insurance commissioners hope to produce by December draft recommendations for an updated model law that states could use to regulate the adequacy of insurers' provider networks, according to a representative of the National Association of Insurance Commissioners (NAIC).

Federal regulators are expected to wait to see the blueprint before deciding how to update their own standards.

The state commissioners are holding a call on Thursday to discuss changes to their model law on network adequacy, said Jolie Matthews, the NAIC senior health and life policy counsel. She spoke last week at a Washington, D.C. forum sponsored by the Alliance for Health Reform.

A subgroup expects to come up with its draft by November or December. Matthews said it probably will not change much before the entire organization adopts it next spring.

The issues of whether provider networks in the new insurance exchanges are too narrow and whether consumers receive up-to-date information about which doctors and hospitals are in networks has captured growing attention in the past year. Under the health care law (PL 111-148, PL 111-152), the Centers for Medicare and Medicaid Services (CMS) are supposed to ensure that provider networks are adequate. But many consumer groups have complained that many of the most important and highest quality hospitals or other providers were left out of some insurers' networks.

CMS officials have suggested that they will more aggressively enforce the standards.

For insurance policies sold in the marketplaces, federal officials mostly relied upon states to review network adequacy in 2014. For the open enrollment season that runs from Nov. 15 through Feb. 15, CMS officials have suggested that they will have closer oversight. A particular focus, they say, will be on mental health providers, oncology treatment providers, primary care doctors and hospitals.

Federal officials more strongly enforce regulations governing Medicare Advantage plans than they do those pertaining to exchange plans, said the Kaiser Family Foundation analyst Gretchen Jacobson.

Commissioners decided to take on the task of coming up with a new state law in order to fend off additional federal rules. State regulators want to protect their authority to evaluate networks, said NAIC's Matthews. The trade association appointed a group in April to start discussing the issue in earnest.

"We're hoping that any thoughts of any federal regulations are stymied now that we're working and hopefully we'll have something early next year," Matthews said.

Any revisions to the model law will probably include requirements that insurers give consumers lists of network providers, she said.

CMS is collecting more data about networks, but the agency does not appear to be policing them more aggressively now, said two other speakers, Steven Shapiro of the University of Pittsburgh Medical Center and American Heart Association senior government relations advisor Stephanie Mohl.

Mohl predicted that federal regulators may probe the makeup of networks more assertively when plans submit proposals to participate in the third open enrollment season that will start in the fall of 2015.

Patient advocacy groups are concerned that consumers may face limited choices of where to get their care because of narrow networks in some places. The American Heart Association released a study last week by Avalere Health showing that in the marketplace plans offered last year, plans' coverage of providers and hospitals varied tremendously. Health plans covered about 11 percent of stroke centers in Atlanta but all of the comprehensive centers in Philadelphia.

"The feds are watching closely what NAIC does and if they think they don't go far enough, I think they will step in and in fact we might advocate that [federal regulators] step in," said Mohl of the Heart Association.

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