In a major win for the insurance industry and a tremendous loss for patients and consumers, health insurers will not be forced to have minimum hospital and physician standards for 2017, nor will they have to offer standardized options in health plans. Health plans will continue to offer so called narrow provider networks which may force patients to drive in some cases hundreds of miles when a specialist is in their community. This provides even greater leverage to healthplans over providers and inconveniences and endangers patients in favor of profits.
(This story was updated at 6 p.m. ET.)
However, the 381-page proposed rule (PDF) released Friday goes a step further, asking states to establish a quantitative measure to ensure ACA policyholders have sufficient access to healthcare providers. If states don’t choose a standard, the CMS proposed a default setting that would measure network adequacy by maximum travel times or distances to providers. Those minimum criteria would be established at a later date, the agency said.
More health insurers have built narrow-network products as a means to control costs. People who select plans with a more limited set of providers generally have lower monthly premiums compared with those who choose broader network plans. But narrower networks have raised the ire of many patients across the country, some of whom have been confused of which hospitals and doctors are actually considered in-network.
The network adequacy proposal is a departure from the model legislation drafted by the National Association of Insurance Commissioners, which is expected to be ratified this weekend. The NAIC draft does not mandate those quantitative standards and instead leaves it up to state insurance regulators. Consumer groups have urged tighter standards like what CMS is proposing.
The CMS wants to make health plan shopping easier for individuals and proposed more “standardized options” for each metal tier. For example, all 2017 bronze options would have a $6,650 deductible, all 2017 silver plans would have a $3,500 deductible and all 2017 gold plans would have a $1,250 deductible. Currently, deductibles and other cost-sharing mechanisms can vary widely within each metal tier, and this would simplify those options for consumers.
“That’s something today we’ve only seen in state-based exchanges,” Elizabeth Carpenter, a vice president at consulting firm Avalere Health, said of the proposed standardized options. “This would make it more like the California or New York models where there are a set of benefits that are the same.”
On the cost-sharing front, HHS is proposing an out-of-pocket annual limit of $7,150 for individuals, up from $6,850 in 2016, and $14,300 a year for families, which is up from next year’s rate of $13,700.
A summary of the proposed rule can be found on the CMS website. Comments are due by Dec. 21.