The AAMC March 7 submitted comments on the Centers for Medicare and Medicaid Services’ (CMS) proposed rule on market stability in the Affordable Care Act’s (ACA, P.L. 111-148 and P.L. 111-152) individual and small group insurance markets. The proposed rule would allow states to determine network adequacy for qualified health plans (QHPs) and decreases the certification requirement for plans to contract with essential community providers (ECPs) [see Washington Highlights, Feb. 17]. The AAMC is concerned that these proposed changes would actually limit consumer choice, restrict access to providers and, leave providers who treat these patients either underpaid or not paid at all.
Beginning with the 2018 plan year, CMS proposes to change its approach to monitoring the network adequacy of plans seeking certification as QHPs. CMS proposes to rely on state reviews for network adequacy in states in which a federally facilitated exchange is operating and where the state has a sufficient network adequacy review process. These proposed changes would supersede the time and distance criteria currently required for QHP certification.
The AAMC is concerned that the proposal to allow states to determine the standards for QHP network adequacy has the potential to exclude teaching hospitals and faculty physicians from exchange plans. This exclusion would be based on these providers being deemed “high cost,” without accounting for the value added by the other missions and societal benefits academic medical centers provide.
In addition, CMS is proposing to lower the regulatory standard for inclusion of ECPs to 20 percent (current requirement is 30 percent) for QHP issuer certification and recertification for plan year 2018. Issuers are eliminating currently offered QHPs and replacing them with plans with narrow provider networks. Exclusions of teaching hospitals and academic medical centers from these networks are often based on providers being deemed “high cost” without accounting for the benefits the institutions provide. The AAMC remains concerned that this reduction in required ECPs will negatively impact vulnerable populations that rely on academic medical centers for their care.