NAIC outlines new rules for health plan provider networks

The National Association of Insurance Commissioners has released draft regulations expected to impact the makeup of health plan provider networks on a state and federal level, including on the marketplace exchanges set up under the Affordable Care Act.

NAIC in November released draft updates to its Managed Care Network Adequacy Model Act, a model law routinely used by state and federal lawmakers when creating insurance laws and regulations, particularly in regards to the creation of health carrier networks and the adequacy and accessibility of services offered under a network plan.

The model Act, which hadn’t been updated since 1996, has been highly anticipated due to the changing insurance landscape under the implementation of the ACA. A controversy over the use of narrow networks on the marketplace exchanges has led the Centers for Medicare and Medicaid Services to investigate the adequacy of provider networks more closely; and the agency said it was waiting for NAIC’s revamped model law before proposing changes to its network adequacy policy for products offered on the 2016 exchanges.

“Accordingly, the model act may have far reaching implications for health plans and provider networks,” says Linda Tiano, a member of the health and life sciences practice at the law firm Epstein Becker Green.

“The NAIC’s model laws are often adopted by legislatures and federal and state regulators, and CMS has stated it will revise its own network adequacy laws based on what the NAIC recommends,” she says in a client alert about the draft Act.  “Accordingly, it is important for any insurer that utilizes provider networks and for the provider networks themselves to understand how these provisions may impact them.”

The draft model law includes several changes to the existing NAIC model, most notably the use of the term “managed care plan” has been replaced by “network plan.”

NAIC says in the draft that the term “is intentionally broad in order to apply to health benefit plans using any type of requirement or incentive for enrollees to choose certain providers over others, such as HMOs, EPOs, PPOs and including accountable care organizations (ACOs) and other models of health care delivery systems.”

Some states may wish to limit the definition by regulation to exclude plans having broad-based provider networks that meet specified standards, the draft adds.

While the model law has always required issuers to ensure and maintain adequate patient access to providers, the draft model law now includes a requirement for health plan issuers to submit access plans to state regulators. States are given the option to require approval of the access plan by the insurance commissioner, or simply require the access plan be filed with the state. 

The draft model law also includes new criteria to be used in determining the sufficiency of a provider network, including geographic population dispersion and new health care options such as telehealth and telemedicine. Under the draft model law, network plans are also required to maintain an online provider directory and update it at least monthly.

Print copies of provider directories must be available upon request, as well as accessible versions of the directories for individuals with disabilities or limited English language proficiency.

The NAIC is accepting comments until Jan. 12, 2015, on the draft model law. 

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