AAFP Urges CMS to Bolster Network Standards on Federal Exchanges

January 21, 2016 11:43 am News Staff

As CMS prepares to update its guidance for insurers on federal exchanges, the AAFP sent the agency a letter emphasizing the importance of creating guidelines that ensure patients can access the primary care they need without disruptions.

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In the Jan. 11 letter(5 page PDF) to CMS Acting Administrator Andy Slavitt, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., focused on the sections of CMS' draft 2017 guidance(www.cms.gov) that deal with network adequacy and provider directories.

Wergin noted that the Academy supports CMS' efforts to address the problem of narrow insurance networks. The agency proposed two measurements for determining whether a network adequately covers a designated area: the maximum time and distance a patient must travel for care or a minimum ratio of physicians to patients for each specialty.

In large metropolitan areas, a primary care physician would have to be within 10 minutes and five miles of a patient. In a rural area, the maximum distance would be 40 minutes and 30 miles. The standards were drawn from those that already apply to Medicare Advantage plans. The AAFP noted that it supports the proposed standards but suggested that such calculations should account for the availability of public transportation.

Story Highlights
  • AAFP Board Chair Robert Wergin, M.D., wrote to CMS that updated guidance to insurers on federal exchanges must ensure patient access to primary care.
  • For example, a measurement of network adequacy that would require patients in large metropolitan areas to be no further than 10 minutes or five miles from an in-network primary care practice should take public transportation into account, Wergin said.
  • The letter also cautioned CMS that its proposals should not promote the practice of dropping physicians from networks without cause or appeal.

"Those who seek care with no transportation available are the most vulnerable and most likely to forgo care simply because they cannot see their physician," Wergin said.

Judgement of network adequacy also should take into account appointment wait times, the AAFP pointed out.

The Academy's letter also asked CMS to minimize the care disruption that comes from shrinking networks, which insurers often refer to euphemistically as "network optimization." Some large insurers have dropped primary care physicians from their plans without giving patients or physicians enough warning or establishing an appeals process for physicians.

"Since the AAFP is convinced that primary care is the most cost-effective access point for care, we believe plans that reduce access to primary care are shortsighted," Wergin said. "The AAFP remains concerned with tactics that health insurance companies deploy that arbitrarily eliminate physicians from networks with little notice and no appeal."

The AAFP expressed reservations about two new provisions CMS proposed to address this issue: 30-day notification to patients whose physicians will be eliminated from a network and permitting patients to continue active treatment for 90 days with a physician who is who terminated from a network without cause.

"We have grave concerns that through this requirement, CMS is acknowledging, if not actually promoting, the practice of issuers terminating providers without cause," Wergin said. "Unfair provider termination from networks without cause continues to undermine the success of federally facilitated marketplaces."

The letter urges CMS to require insurers to establish an appeals process for physicians to review the reasons for their removal from a plan. The AAFP also said insurers should make performance measures and patient feedback used in the decision to drop a physician publicly available.

Finally, the AAFP said network directories should be automated as much as possible so they can be updated without imposing further administrative burdens on physicians. Any changes, such as address or acceptance of new patients, should be capable of being made on a Web-based platform.

Related AAFP News Coverage
AAFP Helps Improve Proposed Rule on 2017 Marketplace Plans
(12/23/2015)

AAFP to CMS: Time to Slow Administrative Busy Work
Proposed 30-day Network Directory Update Draws Academy Ire

(10/8/2015)

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