Health Insurance Health Reform Quality Regulation

Narrow Networks

One of the ways health plans in the health insurance exchanges have been able to keep premiums down is through offering beneficiaries very narrow networks. By steering patients towards “efficient” doctors, premiums stay low. However, patients may worry that these “low cost” doctors are lower quality than those outside of the network. The tradeoff between cost and quality is one health policy wonks have wrestled with for many years.

In an attempt to ensure quality and access to care is adequate, CMS has instituted a number of checks on network adequacy. Tim Jost writes in the Health Affairs blog that qualified health plans (QHP) must:

…must meet network adequacy standards assessed, as in 2015, on a “reasonable access” standard. Insurers must submit detailed network provider data, including information on physicians, facilities, and pharmacies…A QHP insurer must publish a current, accurate, and complete provider directory including information regarding providers accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations.

In addition to ensuring that patients have up-to-date information on which providers are covered by their network, CMS is also mandating that QHPs cover some of the key providers in an area.

For 2016 as for 2015, QHP insurers must contract with at least 30 percent of available essential community providers (ECPs) in their service area, offer contracts in good faith to all available Indian health providers, and offer a contract in good faith to at least one ECP in each ECP category.

CMS will also monitor whether plans are attempting to restrict access to prescription drugs.

Drug formularies will also be monitored more closely for 2016. CMS will review formularies to identify outlier plans with unusually large numbers of drugs subject to prior authorization or step therapy. It will also review formularies to ensure access to clinically appropriate drugs for treatment of bipolar disorder, diabetes, rheumatoid arthritis, and schizophrenia. Other conditions, including HIV, may be considered for future reviews.

It is unclear whether the CMS initiatives will increase quality of care and access to care for patients; it is equally unclear whether these initiatives will drive up plan premiums. We’ll have to wait and see what happens.

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