Insurers dislike CMS plans for network adequacy, plan design

Insurers have objected to proposed changes to network adequacy standards, basic health benefits, and standardized offerings for plans on federal health insurance exchanges, saying the new policy could stifle innovation and have negative consequences for consumers.

CMS issues an annual rule governing exchange plans known as the Benefits and Payment Options Notice. In its proposed rule for fiscal year 2023, CMS announced its intention to reverse Trump-era policies and effectively prevent exchanges, insurance companies, agents and brokers from discriminating against consumers based on their sexual orientation or gender identity. Trade organizations for insurers and providers urged CMS to finalize the repeal of the policy in official comments on the rule.

But insurers are arguing with the agency and provider associations over several other proposals on the giant CMS board.

“We are concerned that some of the policies proposed in this Notice of Payments could take big steps backwards, undermining this hard-won stability and significantly limiting innovation and competition,” wrote AHIP, a major lobbying group for insurers. letter to the agency.

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CMS wants to require insurers to offer standard plan options for every custom plan they use. Standard plans have a single cost sharing structure, and CMS believes this will help consumers compare plans better.

The policy builds on an Obama-era initiative that was later overturned by Trump’s CMS, although the Biden administration goes one step further by effectively requiring standardized plan proposals when insurers have non-standard options. CMS also says the policy change will support President Joe Biden’s 2021 executive order to promote competition in the economy.

AHIP says the policy will stifle innovation among the plans. Requiring standardized plan options for every non-standard plan will only exacerbate consumer “choice overload”, and CMS should instead improve the tools consumers can use to make plan decisions, AHIP argues in its letter. Other insurance trade groups including Community Plans Association and the Public Health Plans Alliance agreed.

Instead, according to AHIP, CMS may only require one Standard Silver Plan option per service area as a test to see if the Standard Plan options meet consumer needs.

The Blue Cross Blue Shield Association writes in its own letter instead, CMS should revert to the previous policy, which allowed but did not require standard plan offerings.

CMS said in the proposed rule that it is also considering resuming meaningful difference standards to help consumers better understand the differences between plans. The standards were originally finalized in the 2015 rule and removed in the 2019 policy. The insurers said this would be a more appropriate policy move than requiring standardized plan proposals.

But associations of health care providers, such as the American Hospital Association and the American Medical Association, want both stricter meaningful standards of distinction and the required standard plan offerings.

The required standardized plan offerings “would benefit consumers by making them easier to understand and use, and by enabling them to better compare plans,” the AHA wrote in its report. letter to the agency.

In addition, CMS proposes that network adequacy reviews be conducted for qualifying health insurance plans in states that use federal exchanges, with the exception of states that conduct their own reviews that are as stringent as those of the federal governments. The federal government conducted these audits from the 2015 to 2017 plan years, but CMS later decided that states had the right to audit supplier networks. However, in March 2021, a district court judge ruled that the policy was unacceptable.

The proposed CMS rule says that checks will be based on time and distance standards, as well as waiting time standards, and they will occur before a qualified health plan is certified. Plans that divide providers into tiers associated with different cost sharing should contract with providers at the lowest cost sharing tier to meet network adequacy requirements.

But AHIP says CMS should rely on government regulators in states that already use quantitative standards in their adequacy checks, develop an alternative standard for rural areas with fewer vendors, and ensure that quantitative tools reflect market dynamics. Requiring insurers to contract with plans at the lowest cost-sharing level, AHIP believes, may make it difficult for plan proposals to be available.

For ACHP, reducing the receive latency seems like a reasonable goal for the network. But adding this measure is not practical during the current public health emergency, the group writes in its letter. ACP also considers CMS should reconsider adding time and distance to network adequacy standards.

Insurers agree that if CMS does finalize these policy changes, they should be delayed until at least 2024.

Meanwhile, the AMA has said it strongly supports CMS’ proposed changes to network adequacy. In fact, the agency could go even further to ensure provider networks are properly serving consumers by measuring network providers’ hours of operation, their ability to take on new patients, their geographic reach, and more. The AHA also supports changes to network adequacy, but acknowledges that current labor shortages are affecting insurers’ ability to build strong networks.

CMS also proposed changes to the requirements for essential health benefits. Exchange plans must cover the minimum set of medical benefits in accordance with the ACA. CMS wants to make it clear in the Core Benefits Non-Discrimination Policy that these benefits must be developed based on clinical evidence.

While the AHA and AMA strongly support the provision, AHIP says the proposal is too broad and could create a “slippery slope.”

“While we agree that discrimination protections are appropriate and necessary to prevent overtly discriminatory benefit plans, the proposed policy would limit issuers’ efforts to create evidence-based exemption plan plans and processes,” AHIP wrote.

AHIP wants CMS to clarify that plans can still set limits on coverage based on clinical evidence. CMS must also provide a full list of what constitutes a discriminatory benefit structure and a cost study that examines the effect of this structure on the cost of premiums. If the CMS finalizes the policy, that should delay implementation, AHIP continues. The ACHP and BCBSA are also asking for more clarity on the proposals and what exactly would be considered a discriminatory design.

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