Provider and consumer groups are criticizing the CMS' decision to hold off on issuing tougher network adequacy rules for health plans, while insurers praised the agency for waiting until state insurance commissioners develop a model rule.
In its proposed rule, the CMS indicated that it will delay issuing additional regulations on provider networks until after the National Association of Insurance Commissioners completes drafting a model state law.
Insurers have insisted that offering plans with narrow networks is a key way to hold down premiums. 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. “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 in their comments objected to the CMS' proposal to require that drug formularies and provider directories be made available in “machine-readable” files, which would allow independent groups to create plan-comparison tools for consumers.
Insurers “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.
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.
Immigration advocates praised the CMS for proposing that exchanges and health plans be required to provide telephone interpretive services in at least 150 languages. But some insurers raised objections to the proposed 150-language standard, arguing it would result in unnecessary expenses and higher premiums.
“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 Wisconsin plan.
