Network adequacy requirements for health plans should focus on making sure consumers have adequate access to different types of services rather than providers, a state Insurance Department official said Thursday.
The state's network adequacy standards have been in the spotlight since the department approved Anthem Blue Cross and Blue Shield's narrow network for individual health plans sold through the Affordable Care Act.
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More companies will be offering plans next year, likely easing some concerns, but officials have said the rules were ripe for revision given how much health care has changed since they were enacted in 2001. The department put together a working group this spring to develop possible updates, and at a meeting Thursday, outlined the progress made in the past few months.
Tyler Brannen, the department's health policy analyst, said focusing on access to services versus providers better reflects changes in health care delivery, for example, nurse practioners provide a lot of primary care in addition to doctors. The standards also should recognize advances in telemedicine by allowing some services to be provided remotely, he said.
"We're hoping this will give people in rural parts of the state renewed access to health care services they wouldn't otherwise get," he said. "To the extent medicine develops along these lines, the Insurance Department and our network adequacy rules should not be a barrier."
Under the framework Brannen described, consumers would be guaranteed adequate access to "core services" such as primary care, pediatrics, urgent care, mental health care and substance abuse treatment within their community, though what constitutes a community has yet to be determined. "Common services" such as radiation oncology, vision care and rehabilitation would be available within "moderate proximity," while services such as heart surgery would be available within the state or near the border. The most specialized services, such as transplants, would be available within New England.
The current law says patients must have access to care "without unreasonable delay" but doesn't get specific. Brannen said the new rules could end up referring to specific wait-time guidelines developed by National Committee for Quality Assurance. Officials also are looking at whether they should change what consequences insurers face for non-compliance. Under current law, those that don't meet requirements can't market their plans in the deficient areas, he said.
Consumers, health care providers, insurers and other stakeholders are encouraged to submit comments to the department by Aug. 21. Depending on that feedback, the department may hold another meeting for discussion or may draft new rules that will be presented to the Legislature for approval. The goal is to have new standards in place by next spring, so they will be applicable to 2016 health plans.