Insurers participating in Obamacare may have to expand their plans to include more federally funded health clinics, safety-net hospitals and other medical providers used by low-income people, under a U.S. proposal.
Health plans offered through government-run insurance exchanges may be required to cover 30 percent of “essential community providers” in their areas in 2015, an increase from 20 percent this year, according to a letter to insurers issued today from the Health and Human Services Department. Insurers’ provider networks will also be reviewed to ensure they provide “reasonable access” to health care.
As millions of Americans join health plans created through the 2010 Patient Protection and Affordable Care Act, consumers and regulators are paying greater attention to the breadth of available coverage. Insurers say smaller networks of hospitals and doctors help contain costs and improve care. Providers serving low-income people have complained that exchange plans won’t allow them to join the networks, said Sara Rosenbaum, a professor of health policy at George Washington University.
“Everybody is obviously very concerned that what’s going to happen is their patients will be swept away -- they will not be identified as preferred providers in networks,” Rosenbaum said in a phone interview. “Clearly something has set off alarm bells.”
About 3 million people signed up as of Jan. 24 for private health insurance plans offered by the new marketplaces, HHS has said. WellPoint Inc., the second-biggest U.S. insurer, said it had added 500,000 members through the exchanges set up by the law known as Obamacare.
More than two-thirds of health plans on exchanges have assembled provider networks considered “narrow” or “ultra-narrow,” in which as many as 70 percent of hospitals and other local health providers aren’t included, according to a December study by the consulting firm McKinsey & Co.
Narrow networks enable insurers to negotiate lower prices with hospitals and doctors, which can be passed on to consumers in the form of lower monthly premiums. The insurance industry argues the practice also enables them to more closely manage the care of patients, benefiting their health.
Exchange plans with broad networks of hospitals carry premiums 26 percent higher, on average, than similar plans from the same carriers with narrow networks, according to the McKinsey study.
“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,” Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry’s Washington-based lobbying group, said in an e-mail.
Federally funded health clinics, public hospitals and other providers that serve low-income people have been lobbying the government for two years to require insurers to more broadly cover their services, Dan Hawkins, vice president for federal, state and public affairs at the National Association for Community Health Centers, said in a phone interview.
“HHS has done a miserable job of establishing a decent network adequacy standard to ensure that insurers are not red-lining low-income communities and communities of color and other vulnerable populations,” he said. “For them to say we’re going to change our rules from 20 percent to 30 percent, that’s whistling past the graveyard. That’s nowhere near adequate.”
Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which oversees the exchanges, said he couldn’t comment on a draft proposal.
“But, in general, CMS is working to strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act,” Albright said in an e-mail. “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.”
Albright’s agency said in the letter that if it determines a health plan’s provider network is inadequate it may exclude it from the exchanges. The agency said it would particularly focus on insurers’ coverage of hospitals, mental health clinics, cancer centers and primary care physicians.
Ideally, the government would require insurers to contract with every essential provider in their service areas, Hawkins said. In addition to community health centers and public safety-net hospitals, essential providers include AIDS clinics, family planning clinics, children’s hospitals and other facilities qualifying for a federal program that provides deep discounts on drug prices, Rosenbaum said.
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