Insurers are at odds with providers and consumer advocacy groups over the Obama administration's guidance on network adequacy. In the proposed rule, the CMS indicated that it will hold off on issuing additional regulations dealing with provider networks until after the National Association of Insurance Commissioners completes drafting a model state law.
Narrow networks have been a major source of contention since the exchanges launched. Insurers have insisted that limiting networks is a crucial means of holding down premiums, and exchange customers have flocked to low-cost plans. But consumer advocates and providers worry that unsophisticated customers are choosing plans that may not include their doctors or otherwise meet their coverage needs.
That division played out in comments to the CMS about a proposed rule for 2016 enrollment. Insurers praised the agency for deferring to the NAIC process before drafting additional network adequacy regulations, while hospitals and consumer groups called for more aggressive action.
“CMS should not delay further the development of more robust network adequacy requirements and more effective oversight and enforcement mechanisms,” wrote Chip Kahn, CEO of the Federation of American Hospitals. “Rather, CMS should instead adopt and adapt the Medicare Advantage network adequacy standards for the marketplaces.”
Insurers also are raising objections to the CMS' proposal to require that drug formularies and provider directories be made available in “machine-readable” files. That would allow third parties to create tools to help consumers to make more informed choices about which plans would best meet their needs.
But health plans suggested that it could put them at a competitive disadvantage and confuse customers. “If issuers were required to post machine-readable files for general consumption by third parties, issuers would have no ability to ensure that their benefit information was correctly represented by those third parties,” wrote Anthony Mader, Anthem's vice president for public policy. “Inaccurate information not only would increase the burden on issuers; it also would create consumer confusion and potential dissatisfaction.”
The CMS also proposed that insurers be required to use pharmacy and therapeutics committees to advise them on drug formularies. Some patient advocacy groups have complained that crucial drugs are only available at top-tier pricing and are therefore unaffordable for many consumers. There's also been concerns raised about a lack of transparency with regards to drug formularies.
"We have heard from members that many patients have had difficulty determining how/if exchange plans will cover their prescription drugs," the American Pharmacists Association said. "Plan beneficiaries will benefit significantly from clear, up-to-date information regarding prescription drug coverage."
Immigration advocacy groups are urging the CMS to establish a “language access coordinator” to help ensure the needs of exchange customers with limited English proficiency are being addressed. They noted the Federal Emergency Management Agency already has such a position to help non-native speakers gain access to information and services.
Immigration advocates also praised the CMS for proposing that exchanges and health plans be required to provide telephone interpretive services in at least 150 languages. But they questioned why there should be any limitation on language assistance. Instead, they'd like to see the agency require interpretive services in any language requested.
However, some insurers raised objections to the 150-language standard being proposed by the CMS, arguing it would result in unnecessary expenses and higher premiums. “While we acknowledge the need for translation services and currently provide this to our members, we believe that any requirement should instead be tied to an issuer's respective member demographics in order to avoid needless administrative expense and burden,” wrote Cathy Mahaffey, CEO of Common Ground Healthcare Cooperative, a not-for-profit health plan operating in Wisconsin.
The National Immigration Law Center is also calling on the CMS to adopt more stringent guidelines for when exchanges and health plans must provide written materials in a foreign language. There were widespread complaints during the first year of enrollment that many non-English speakers couldn't understand letters alerting them to problems with their immigration documents and therefore risked losing coverage.
The CMS has suggested requiring that anytime a health plan or web broker has at least 10,000 customers who share a primary language other than English, they must provide written materials in that language. The NILC wants that provision strengthened to require that translated versions of materials be provided anytime a language group makes up 5% or 500 customers, whichever threshold is lower.
But insurers objected to even the 10,000-customer standard floated by the CMS. Blue Shield of California noted it would require the health plan to provide materials in 48 languages.
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