“I know if I’m in network, it helps my patients, but not if I don’t get paid appropriately and can’t keep the lights on.”
its regulations prohibits balance billing, as some stakeholders requested. Ac- knowledging the cost-sharing policy “will help provide transparency and … a measure of financial protection for consumers against surprise out-of-network cost sharing,” the agency deferred it to 2018 “to permit us to monitor ongoing efforts by [plans] and providers to address the complex issue of surprise out- of-network cost sharing at in-network facilities … and amend our policy in the future to accommodate progress on this issue, if warranted.” NAIC calls the updates to its 1996 model network adequacy act “a major im-
provement” that reflects “a compromise among all of the participating stake- holders.” A spokesperson tells Texas Medicine, “State insurance regulators must have the flexibility to regulate provider networks based on appropriate consid- erations such as geographic access and impact on premiums. They also need to make sure consumers can access clear information on which providers are in the network of each plan. The model does not regulate [physician] billing practices, but establishes protections for consumers in very specific situations where a person goes to an in-network facility and then finds out a provider in the facility is out-of-network.” AHIP, the Blue Cross Blue Shield Association, and Aetna all participated in and endorsed the final NAIC model bill. TMA officials clarify the federal regulations do not supersede stronger state
laws but say CMS’ reversal represents a significant setback. Medicine strongly rejects the NAIC model act for “lack[ing] meaningful standards,” TMA writes in an Oct. 31, 2015, letter to NAIC and CMS officials. Consumer groups like Fami- liesUSA agree (tma.tips/NAICModelFamiliesUSA). Comments filed by TMA and the American Medical Association throughout the two-year development process continually urged regulators to focus on their charge of holding plans’ feet to the fire for ensuring fair contracting and robust and transparent networks. Instead, the final model “serves to reward insurance companies for their poor marketplace conduct and signals to other insurers to reduce investment in net- work adequacy, especially in emergencies,” TMA’s letter states. TMA and TDI officials say Texas’ network adequacy standards already meet
or exceed provisions in the NAIC model bill, for example, by imposing specific time and distance criteria, provider directory standards, regular reporting, and random sampling to verify insurers’ panels. BCBSTX also told Texas Medicine the NAIC model contains provisions similar to existing Texas law, adding that it supported the recently expanded state mediation process. TMA and TDI officials say Texas’ mediation model, which NAIC rejected, is
working: 94 percent of the roughly 1,000 requests TDI has received have been resolved in early conference calls without proceeding to formal mediation. TMA’s task force recommendations contemplate expanding availability of the mediation process for all out-of-network services and additional state oversight of health plans that repeatedly end up in mediation. TMA adds Texas also could take stronger laws that already exist for HMOs
and super-narrow EPOs and apply them across the board to PPOs. In emer- gency situations, HMOs and EPOs must find a way to hold patients harmless by paying non-network physicians adequate rates to prevent a balance bill. In nonemergency cases, HMOs and EPOs must fully pay the physicians needed to fill network gaps, either an agreed-upon rate or physicians’ full billed charges. “Creating adequate provider networks with payments that allow physicians
to keep their doors open is the responsibility of insurance companies, not physi- cians or patients,” Dr. Valenti said. n
Amy Lynn Sorrel is associate editor of Texas Medicine. You can reach her by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
amy.sorrel@
texmed.org.
36 TEXAS MEDICINE May 2016
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