The Obama administration is proposing to widen provider networks and increase access to prescription drugs in health plans that participate in marketplace plans in 2016.
“It is one of our many goals to strengthen the integrity of programs that fall under the Affordable Care Act to ensure the delivery of quality care with affordable options,” said Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner, in a statement. “CMS is working to improve the consumer experience and promote accountability, uniformity and transparency in private health insurance.”
Marilyn Tavenner
According to the proposal, issued on Nov. 21, the administration “continues to take great interest in ensuring strong network access.” The CMS is proposing that only hospitals and physicians that are in-network can be considered part of the network. Out-of-network providers cannot be included to demonstrate adequacy.
For now, insurers will have to follow standards issued by the agency in March, but changes could come by the time the 2016 proposal is made final.
The agency says it is waiting to see the final results of a model law on network adequacy that’s being developed by the National Association of Insurance Commissioners. A draft of that proposal was recently released and comments are due by Jan. 12.
The CMS also is proposing that new enrollees be given 30 days to transition from current physicians or hospitals to the new plan’s network.
Health plans also will be required to publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations. The guide has to be easily accessible – without having to create an account or use a policy number – to plan enrollees, prospective enrollees, states, and marketplace plans. It should be updated at least once a month, said the CMS.
The agency also is proposing changes to how marketplace plans cover prescription drugs. Currently, plans are required to cover at least one drug in each class.
But plans have had trouble meeting that requirement, and there were other problems, including that the criteria did not exactly encourage newly approved drugs to be included, according to the agency.
Instead, it is proposing that plans use pharmacy and therapeutics committees – following specific standards set out by the CMS – to review and approve drugs, and that it be an adequate amount in each class.
Drug formularies also should be easily accessible to the general public, without having to create and account or give a policy number, and it should be up to date, according to the proposal.
The proposal is open for comment until Dec. 21.
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