Providers say the CMS isn't doing enough to protect consumers from receiving surprise bills or to ensure low-income exchange enrollees have access to care.
Surprise medical bills come when consumers get care at an in-network facility by an out-of-network specialist. Many times this happens because their insurer hasn't properly informed its customers.
In a proposed rule that outlines coverages policies for plans in 2018, the CMS suggested that plans should count enrollee cost sharing for care provided by an out-of-network provider at an in-network facility toward the enrollee's annual deductible . The agency proposed the policy for plans both and off the exchange. CMS received 664 comments on the proposed rule by its Oct. 6 deadline.
It also suggested plans could more actively inform enrollees about to get services from an out-of-network provider. But doctors and hospitals felt the agency should have gone further in protecting consumers.
“We believe CMS' proposals fall short,” Tom Nickels, executive vice president of the American Hospital Association said in a comment.
The trade group suggested that CMS embrace a policy suggestion made by the National Association of Insurance Commissioners that allows consumers to appeal the bills through a mediation process between the health plan and the out-of-network provider.
Insurers should also be required to use standardized language to describe their out-of-network coverage, Dr. James Madara, EVP and CEO, American Medical Association added in a comment.
Payments to non-participating providers reflect the cost of providing that care. Such fair coverage will reduce cost-shifting onto patients and maintain reasonable incentives for insurers to create adequate networks that provide access to hospital-based care, Madara said.
The rule also attempted to ensure access to care for low income enrollees by proposing to continue a 2017 policy that each plan on the exchange include at least 30% of all available safety net providers, referred to in the rule as essential community providers, in a service area. The agency also sought feedback on whether the policy should be updated in future years.
America's Essential Hospitals is pushing to have plans cover all essential community providers in a region. That would give people in typically poorer, underserved areas more options for care.
"The current standard is not stringent enough to ensure all types of essential community providers are included in provider networks,” Bruce Siegel, president and CEO of the trade group said in a comment letter.