“Physicians are the ones who will be left hanging, and that is a significant concern.”
plans to the point where even health plans can’t tell us who’s in or who’s out,” Dr. Chenven said. Physician participation in the exchange isn’t mandatory.
While ARC opted in to two marketplace plans, it wasn’t until after the launch that the clinic discovered it had automatically been included in a third insurer’s marketplace plan. “There was no communication whatsoever,” Dr. Chenven said. ARC chose to stay in that plan, “but it represents another example of the confusion of this whole transition. And, frankly, health plans’ performance could be greatly improved.” TMA officials recommend physicians check their contracts and call their health plans to confirm inclusion in exchange plans. (See “Untested Waters,” December 2013 Texas Medicine, pages 37–43, and “Marketplace Q&A,” page 24.) Nacogdoches Area Physicians Association Executive Direc-
tor Leesa Barnhart questions the adequacy of certain market- place networks when only seven of its 115 member-IPA physi- cians participate in the Blue Cross and Blue Shield of Texas (BCBSTX) HMO exchange plan available. Out of a dozen plans participating in the Texas marketplace, the Blues is the only carrier in the Nacogdoches area, and the HMO plan is one of just two marketplace plans offered there. Access TMA’s market- place map online,
www.texmed.org/ExchangeMap. “There are not enough doctors in Nacogdoches [for this plan] to have a good panel. There are seven doctors in the panel — period. And, frankly, I’m not sure if they all know they are in it,” Ms. Barnhart said. Already one physician opted out upon discovering that the low payment rates offered, which barely matched Medicaid rates, would not cover the practice’s costs. Others with similar contract offers “decided they weren’t going to touch it with a 10-foot pole,” she said. A CMS spokesperson said the agency “is working to
strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act.” The federal government issued new draft regulations in
February that in 2015 require marketplace plans to include in their networks at least 30 percent of available essential com- munity providers that serve predominantly low-income, medi- cally underserved populations, up from 20 percent in 2014. Health plans also must offer contracts in good faith to these and other groups and provide justification if they can’t meet the 30-percent threshold.
22 TEXAS MEDICINE April 2014
At press time, TMA was reviewing
the proposal for possible comment. “These are important provisions and include requirements that insur- ers have adequate provider networks for consumers,” the CMS spokesper- son said. For 2015, CMS will collect network data as part of the federal approval process for health plan participation or renewal in the marketplace. For 2014, CMS didn’t collect such infor- mation and instead relied on state reviews of network adequacy, among
other qualifications. CMS says the change will allow the agency to assess whether the plans’ networks meet the statu- tory and regulatory certification requirements and expects im- proved access for enrollees.
Still, the agency maintains that it has broad oversight authority over marketplace plans and says these and other mechanisms, including requirements that plans publish their provider lists, allow CMS to take appropriate action against in- surers, if necessary. CMS didn’t directly respond to Texas Medi- cine inquiries regarding how they hold health plans account- able for keeping those lists current. Texas plans participating in the exchange also must follow state rules such as network adequacy and prompt pay. (See “Ready, Set …?” August 2013 Texas Medicine, pages 49–54, or visit
www.texmed.org/Essen tialBenefits.) BCBSTX Chief Medical Officer Dan McCoy, MD, says the
carrier “worked thousands of hours to prepare for the ACA, creating adequate networks that serve all 254 Texas counties.” The Blues updates its provider directories at least twice weekly and “frequently reviews its networks across the state and pro- actively recruits health care providers to ensure adequate cov- erage and options for our members by specialty and geograph- ical area.” BCBSTX is the only statewide marketplace insurer. Aetna says it updates its directories six times per week and sent notices to physicians in the fall indicating in-network sta- tus for the carrier’s marketplace plans. Neither BCBSTX nor Aetna directly responded to Texas
Medicine inquiries about whether physician opt-outs from ex- change plans have since affected network adequacy. Nor did the Blues say how it would handle CMS’ “smooth
transition” rule.
Aetna says it will review patients’ circumstances case by case, but in general would respond in one of two ways:
• If Aetna can substantiate that its provider information was/ is inaccurate at the time the member accessed it, the insurer would cover benefits at an in-network rate.
• If Aetna can’t substantiate that information or the member made an error, the member would be responsible for the cost of the out-of-network care.
Cigna declined to comment for this story.
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