Feds release guidance on reference pricing, network adequacy in ACA group plans


The Departments of Labor, Treasury and Health and Human Services released a frequently-asked question document offering guidance on the use of reference pricing in non-grandfathered large group employer plans. This may be the first time the departments have tried to regulate group health plan network requirements under the Affordable Care Act, according to a Health Affairs blog post by attorney Timothy Jost.

In evaluating a plan's reference price design, the government will consider whether the payer is "using a reasonable method to ensure adequate access to quality providers at the reference price," the guidance stated.   

A key concern is whether plans have standards to ensure that their networks offer high-quality providers at reduced costs; reference pricing arrangements shouldn't serve as "a subterfuge for otherwise prohibited limitations on coverage," the FAQ stated.

There are several takeaways on this point: First, "pricing that treats providers that accept reference prices as the only in-network providers must do so only for services where there is sufficient time between when the need is identified and when the service is provided and allow the consumer to make an informed choice of provider," Jost wrote. And limiting or excluding cost sharing for providers who don't accept the reference price "would not be considered reasonable with respect to emergency services," the FAQ noted.   

Payers should ensure that enough providers who accept reference prices are available to customers. To achieve this, payers should consider network adequacy approaches developed by states along with "reasonable geographic distance measures." Insured group plans are independently subject to applicable state regulations for network adequacy, Jost noted. Payers should also consider whether patient wait times are reasonable.

Moreover, insurers should impose quality standards on providers who accept reference prices. And there should be an "easily accessible" exceptions process letting patients use providers who don't accept reference prices when those who do aren't available or can't provide quality care required for patients with specialized needs.  

Finally, plans must provide disclosures to the government automatically and by request. These will include information on the pricing structure, including a list of services to which it applies and a description of the exceptions process, Jost wrote.          

For more:
- read the federal government's FAQ document
- here's the Health Affairs blog post

Related Articles:
Insurers embrace reference pricing
Is reference pricing in line with ACA goals?
Holes in the argument for reference pricing
Reference pricing saves CalPERS $5.5 Million
Obama administration okays reference pricing
Reference pricing saves insurers, patients money