Since the Affordable Care Act (ACA) became effective, the main complaints patients have had have been inaccurate provider directories and higher than expected out-of-pocket costs for the plans sold on the health insurance exchanges.
Federal officials announced that beginning in 2016, they will require qualified health plans (QHP’s) sold on the exchange to update and correct their provider directories at least once a month. Furthermore, plans sold on the exchanges for the 2016 plan year will be required to provide an out-of-pocket cost calculator so individuals can have a better sense of anticipated expenses when selecting a plan.
Inaccurate or outdated providers/health professional directories are not unique to the exchange market; they exist for Medicare Advantage and Medicare managed care plans as well. To address Medicare directories, federal rules will require insurers to update their Medicare directories each month, “with specific notations to highlight those providers who are closed or not accepting new patients.”
After premium cost, the provider network is the single most import factor to consumers when they pick a health plan – which means keeping provider directories accurate is extremely important. Consumers want to know: “Is ‘my’ hospital or ‘my’ physician in the plans’ network?”
Equally important, if a patient has coverage for a service but can’t get access to that service due to inaccurate information, the patient faces unnecessary and avoidable burdens. Moreover, going outside the network typically imposes additional costs on the consumer that they might not have expected.
The new Qualified Health Plan requirements are consistent with earlier efforts by the Obama administration to mandate that insurers publish information on:
- Health professionals who are accepting new patients.
- Physician specialty and medical group affiliation.
- Current contact information.
Insurers must also provide the data in a format consumers can use to help them identify health plans in which their doctors participate. Failure to comply will be met with financial penalties.
The calculator mandated under this new policy will take into account the QHPs premiums, subsidies, copayments, deductibles, and other out-of-pocket costs, as well as a person’s age and medical needs (including expected medical procedures such as childbirth).