CMS aims to broaden exchange provider networks


Insurers selling plans on health insurance exchanges may soon have to broaden their provider networks to include 30 percent of essential community providers in their area--or risk being kicked out of the online marketplaces.

Under a new policy proposed in a letter Tuesday, the Centers for Medicare & Medicaid Services would require insurers to include more federally-funded health clinics, safety-net hospitals and other providers that low-income consumers typically use. They're currently required to include 20 percent of these providers in exchange plans.

"CMS is working to strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act," CMS spokesperson Aaron Albright told Bloomberg. "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."

If the policy becomes final, exchange plans may have fewer narrow networks, which insurers claim help lower premiums. In fact, a December study found exchange plans with broader networks average 26 percent higher premiums than similar narrow network plans.

America's Health Insurance Plans pushed back against the CMS proposal, saying it could hurt quality and costs. "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," AHIP spokesman Robert Zirkelbach told Bloomberg.

CMS added in the letter that it would review insurers' provider networks to guarantee they provide "reasonable access" to healthcare and would particularly focus on whether insurers cover hospitals, mental health clinics, cancer centers and primary care physicians.

To learn more:
- here's the CMS letter (.pdf)
- read the Bloomberg article

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