Proposed Changes to Federal Exchanges Elicit AAFP Comments

Academy Urges CMS to Maintain Primary Care Focus

December 23, 2014 01:20 pm News Staff

Nearly one year after open enrollment began on the federally facilitated health insurance exchanges established as part of the Patient Protection and Affordable Care Act, CMS is proposing(www.gpo.gov) several significant changes that, if finalized, would take effect during the 2016 coverage year. A number of the proposals would improve patients' ability to make decisions about coverage.

[Doctor taking obese, black male's blood pressure]

A major issue under consideration is how many primary care visits would be covered by health plans sold on the federal exchanges during a calendar year. CMS initially proposed that it would "encourage" insurers to cover three primary care visits before any cost-sharing kicked in.

In a Dec. 18 letter to the agency,(4 page PDF) however, the AAFP wrote that CMS should require such "first-dollar" coverage for three visits because many individuals who obtain insurance on the exchanges -- especially those who were previously uninsured -- will have multiple ailments that could necessitate more than one visit.

"The three-visit requirement would provide an appropriate incentive to beneficiaries to see their primary care physician in a patient-centered medical home to address those ailments and thus prevent costlier care down the road," said AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., in the letter.

Another pending change would be a requirement that each marketplace plan establish a pharmacy and therapeutics committee that would be responsible for determining which drugs to include on plan formularies. This committee would set recognized standards for each plan to ensure a broad array of prescription drugs were available to patients, a concept the AAFP said it supports.

Story highlights
  • In a recent letter, the AAFP urged CMS to require health plans on the federal exchanges to cover three primary care visits with no cost-sharing each year.
  • The Academy also laid out its concerns about insurers' seemingly arbitrary network narrowing practices and agreed with the agency's proposal that insurance carriers be required to update their provider databases once each month.
  • In addition, the AAFP supported CMS' plan to require health plans that participate on the exchanges to have a pharmacy committee that, according to the AAFP, should be composed only of practicing clinicians who have prescriptive authority.

CMS also sought input from the medical community about the membership composition of the committees. The agency has proposed drawing members from "a sufficient number of clinical specialties to adequately represent the needs of enrollees."

Noting the diversity of patients and the wide variety of illnesses family physicians treat, the AAFP strongly encouraged CMS to mandate that some committee seats be set aside for family physicians. The Academy also recommended that membership consist only of practicing health care professionals with prescriptive authority.

Uncertainty among both physicians and patients about the composition of insurers' provider networks has also grown recently in light of some carriers' decisions to limit the number of physicians in one or more of their plans' networks.

"The AAFP is growing increasingly concerned with tactics deployed by health insurance companies whereby they arbitrarily eliminate physicians from their network, forcing patients to identify and secure the services of a new physician," said Blackwelder in the letter. "This so-called 'network optimization' is disruptive to patients and their physicians, and the AAFP urges CMS and plans to minimize such actions."

On a related note, the Academy supported a CMS proposal that calls for insurers to update their provider network directory information at least once each month and to make it easy for patients to determine whether a physician participates in a specific plan's provider network if the insurer maintains multiple networks.

Finally, Blackwelder's letter addresses a CMS proposal that would allow consumers greater leeway when making decisions about plan re-enrollment from year to year.

Noting that patients evaluate insurance plans based largely on premium price, the agency is exploring a policy whereby patients could choose to be re-enrolled by default into a low-cost plan identified according to specific criteria rather than into their current plan or the plan identified in the current re-enrollment hierarchy.

In response, the Academy noted that although it recognizes "the high value consumers place on low premiums," it cautioned against creating a re-enrollment mechanism that functions entirely as a cost-saving measure.

"The AAFP urges CMS to help educate consumers about the risks of being default re-enrolled in a plan with a significantly different provider network, benefits, cost-sharing structure or service area," said the letter.