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Insurers selling exchange plans would have tougher standards in 2015, CMS proposal says

Insurers that want to sell plans through the federal exchanges for 2015 may have to do more to ensure members have access to adequate networks of providers.

Participating health plans would be required to submit a list to the CMS of all in-network providers and medical facilities covered under a plan, according to a proposal detailed in a letter from the CMS on Tuesday. The CMS will review them, in conjunction with state regulators, to ensure that there is “reasonable access” to all types of providers.

“It looks like they're going to be taking a much more serious look at network adequacy,” said Timothy Jost, a healthcare expert at Washington and Lee University School of Law.

Insurers' use of narrow networks to hold costs down for their 2014 exchange plans has generated some backlash from providers that were left out. State lawmakers in New Hampshire and Mississippi are considering legislation that would push insurers to open their plans to more providers, and hospitals in Washington and Kentucky have complained to state officials that they were unfairly shut out of important networks.

The CMS letter proposes new standards for providing access to “essential community providers,” which serve predominantly poor and medically underserved neighborhoods. Plans sold through the federal exchange in 2015 will be required to include at least 30% of such providers in the territory covered. In 2014, that standard was only 20%. If plans fail to provide that level of access to essential community providers, they'll need to provide an explanation as to why their product should still be allowed to be sold on the exchange. The CMS will then determine if that explanation is adequate.

“As only one issuer submitted a justification for the 2014 benefit year as a means to satisfy the 20 percent ECP standard, we anticipate that our intended proposal of the 30 percent ECP standard to the 2015 benefit year will be a feasible standard for issuers to satisfy,” the letter states.

The CMS also indicated that it is considering requiring all exchange plans—or at least one plan at each level of coverage, per insurer—to cover at least three primary-care office visits each year prior to incurring any deductible. So far, the federal agency is merely encouraging health plans to provide that coverage. Jost suggested that such a requirement may be a means of enticing younger, healthier individuals into the exchange by guaranteeing access to a certain level of free care even for high-deductible plans.

Insurers will need to submit plan details to the CMS by June 27 for products they wish to sell during the 2015 enrollment period.

The public can offer comments on the proposals laid out in the letter until Feb. 25.

There will be two review periods over the summer during which federal officials will notify insurers about any deficiencies in their applications and allow them to submit changes. Signed agreements for products to be sold through must be finalized by Oct. 17. The open-enrollment period starts Nov. 15.

The 2015 open-enrollment period was initially supposed to run from Oct. 15 to Dec. 7. But in November, the Obama administration announced that the sign-up period would instead run from Nov. 15 to Jan. 15. The explanation for the delay was that it would allow insurers additional time to evaluate the marketplace for the current year and come up with more accurately priced products for 2015.

Follow Paul Demko on Twitter: @MHpdemko



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