CMS Proposes HIX Guidelines for 2015

Federal regulators overseeing public health insurance exchanges are taking a fresh look at adequacy standards for so-called narrow networks, which insurers say are an essential tool for controlling healthcare costs.

In proposed guidelines released Tuesday, CMS is seeking to pry open narrow networks with stricter standards for network adequacy and inclusion of more providers who serve low-income and medically underserved patients.

"CMS is working to strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act," a CMS spokesperson told HealthLeaders Media on Wednesday. "These are important provisions and include requirements that insurers have adequate provider networks for consumers, including access to essential community providers that serve low-income, medically underserved individuals."

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Part of the CMS guidelines released Tuesday call for a more stringent review of applications to offer health insurance policies on the public exchanges: "CMS will review the collected provider list to evaluate provider networks using a 'reasonable access' standard, and will identify networks that fail to provide access without unreasonable delay as required. … To determine whether an issuer meets the 'reasonable access' standard, CMS will focus most closely on those areas which have historically raised network adequacy concerns."

The focus points for the proposed 2015 network adequacy review process include hospital systems, mental health providers, oncology providers and primary care physicians.

The proposed guidelines also seek to increase the percentage of essential community providers in an exchange network's service area from 20 percent to 30 percent.

Insurers say they need to craft narrow networks to contain costs and offer health plans that public exchange policy holders can afford. Anthem Blue Cross Blue Shield of NH officials have said they designed a narrow network for the Granite State's federally administered exchange because they faced premium increases forecast as high as 40 percent.

"It is important to ensure patients can continue to benefit from the high-value provider networks health plans have established, which are helping to improve quality and mitigate cost increases for consumers as the new health care reforms are taking effect," said Robert Zirkelbach, vice president of strategic communications for America's Health Insurance Plans.

But providers who have been frozen out of narrow networks say the proposed new guidelines are necessary to avoid certifying networks that are at odds with the spirit of PPACA-driven health care reforms.

"That's exactly what I have been talking about," says Peter Wright, president and CEO of Valley Regional Hospital in Claremont, NH. "There's the narrow network that excludes a whole community, and I have a problem with that."

Anthem's network in New Hampshire's exchange excludes 10 of the state's 26 acute-care hospitals, including VRH. The hospital serves Sullivan County, which has no public transportation, an economically disadvantaged population, and poor healthcare outcomes compared to other counties in the Granite State. "How can you not look at that as classism?" Wright said.

Many of VRH's patients face not only changing primary care doctors but also drives as long as 90 miles for services. "The narrow network that was implemented here excluded Sullivan County and I want to see that changed," Wright said.

Wright says another change he would like to see is adoption of an "any willing provider" feature in the public exchanges similar to a proposal before lawmakers in the NH Statehouse. "Anybody who is willing to accept the fee schedule can be a part of that network," he said.