The CMS faces a daunting task in finalizing regulations for health plans sold on the federal exchange in 2017, given insurance and business groups' strong pushback to the agency's proposed rules issued in November.
Insurers urged the agency to nix certain consumer protection and rate-transparency provisions, while provider and consumer groups favored those provisions.
There is growing criticism that Affordable Care Act plans offer inadequate coverage in terms of affordability and provider access. On the other hand, insurers led by UnitedHealth Group have threatened to abandon the ACA exchanges in 2017 if the rules and the risk pool make that business unprofitable. Now the Obama administration has to figure out how to find a balance.
More than 500 comments were submitted on the proposed rule, many slamming the CMS' proposals to more tightly regulate provider networks and standardize plan options. Critics said these provisions would hurt insurers' ability to keep premiums down.
“Unless some fundamental flaws are corrected, we believe there is a grave risk that the federal exchange will not operate as a viable, competitive market in 2017,” wrote Steven Kelmar, Aetna's executive vice president for corporate affairs.
The CMS proposed that all plans sold on the federal exchange would have to include hospitals and doctors within certain travel times or distances from members.
There also would be minimum provider-to-member ratios for certain medical specialties. The goal was to ensure that consumers had adequate access to providers as more insurers moved to narrow-network products.
Many hospital and doctor groups supported the proposal. The American Academy of Family Physicians asked the CMS to go a step further and set network standards for appointment wait times.
But the CMS proposal was a big departure from the recently approved model law drafted by the National Association of Insurance Commissioners, which would let state insurance departments establish criteria for network adequacy.