CMS takes action to stabilize ACA insurance market

April 24, 2017

It has often been said that when it comes to health insurance, what’s good for the insurance company may not be good for the physician or patients. That sentiment certainly seems to ring true with the newly announced “market stabilization” regulations recently finalized by the Centers for Medicare and Medicaid Services (CMS).

While members of Congress have been busy pondering how to repeal and/or replace the Affordable Care Act (ACA), CMS has been moving forward with regulations the agency maintains will “stabilize” the existing health care exchange marketplace. They will accomplish this objective primarily by easing requirements on health insurers.

There is no question that many of the market regulations adopted during the Obama Administration added to the cost of the insurance products sold on the federal exchanges. And it seems likely these new regulations (or rollback of existing regulations) could result in lower premiums for some plans sold on the exchanges.

Unfortunately, this effort at premium reduction will likely come at a cost to you – and your patients’ ability to choose the physician from whom they wish to receive care.

One of the recurring concerns we hear from patients and members is about insufficient networks and the detrimental impact this has on patient care. Earlier this year, the Advocacy Council wrote to CMS urging it to reject requests from health plans that the network adequacy standards be relaxed. The College supported the rules on network adequacy adopted by the Obama Administration, pointing out that referral of patients with asthma to an allergist-immunologist saves money and improves patient care.

Unfortunately, our recommendations were not adopted by CMS. Even though ACA plans will still have to provide members with a “sufficient choice of providers,” CMS is deferring enforcement of this to the states or private accreditation bodies - many of whom do not have quantitative standards. This means the narrow network problem will, if anything, get worse; at least for the time being.

In a related change, plans will only be required to include 20% (rather than the current 30%) of “essential community providers” in their networks.

Other efforts to stabilize the market include shortening the annual open enrollment period and allowing insurers to charge patients for past due premiums, as well as increasing insurer flexibility to add additional plans with lower premium options.

Having stable and predictable insurance markets can, in the long-run, be beneficial to patients and physicians. But if markets are going to function properly, there must be a balancing of interests between health plans, patients and providers. It seems evident that the changes made by these new regulations will make the marketplace more attractive to health plans and increase the likelihood that they will not abandon the exchanges. But at what price?

After all, what value is an insurance policy if the patient does not have access to the types of physicians and hospitals that can treat the medical problems that confront patients with chronic medical conditions such as asthma or allergies.

If, as a result of the relaxed network adequacy standards, health plans are able to reduce the already limited number of A/I physicians in their networks, will this be in the best interest of patients who suffer from allergies and asthma? The Advocacy Council will continue to monitor this situation and advocate for our specialty.