AAFP Calls on CMS to Improve Access, Outcomes With Exchange Rules

October 11, 2016 04:00 pm News Staff

The AAFP is urging CMS to make sure that rules governing federal health insurance exchanges contribute to improved patient access and health outcomes.

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AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., made the case to CMS Acting Administrator Andy Slavitt in a detailed letter(5 page PDF) sent in response to a proposed rule for health plans participating in the exchanges in 2018,(www.gpo.gov) which was published Sept. 6 in the Federal Register. Each year CMS revises the rules for insurers that participate in the exchanges.

A major theme expressed in the Oct. 6 letter is the need to protect patients against reduced competition and sudden changes by insurers that could restrict or eliminate their choice of physician or health facility.

"Lack of competition in health plans could be a serious concern during the 2017 enrollment period," Filer wrote. "The AAFP believes this proposed rule could provide the exchanges with needed flexibility and encourage continued participation by qualified health plans."

Story Highlights
  • CMS published a proposed rule that makes revisions for insurers that participate in the federal health insurance exchanges.
  • The AAFP sent a detailed letter to CMS highlighting the need to protect patients against reduced competition and sudden changes by insurers that could restrict or eliminate their choice of physician or health facility.
  • The letter also urged the expansion of plans that offer more preventive services with no cost sharing for patients who visit in-network physicians.

To give consumers a range of choices, CMS proposed requiring insurers to offer silver and gold plans in each market where they participate. In the past some insurers offered fewer choices on the exchanges than they did in the commercial marketplace. The AAFP supports the proposal because low-cost plans are necessary to recruit the younger, healthier beneficiaries that the exchanges need, Filer wrote, and plans offering greater coverage are needed for middle-aged beneficiaries with ongoing medical needs.

"Ensuring consumer choice for silver and gold coverage for each service area in which the plan offers health insurance would expand options and increase enrollment," Filer wrote. "In addition, allowing for greater flexibility in bronze plans should help those who find it difficult to obtain health care coverage or see little value in purchasing health insurance."

The AAFP also urged the expansion of plans that offer more preventive services with no cost sharing for patients who visit in-network physicians, even when the deductible has not been met. The letter called on CMS to consider whether these models should be available throughout the exchanges with the eventual goal of eliminating any patient cost sharing for most primary care services.

"The AAFP appreciates CMS recognizing and encouraging the value of primary care for patients who would enjoy full coverage for that care before those costs are subject to the deductible," the letter stated. "Fully covering preventive services makes health insurance more attractive to young and healthy people and makes it easy for them to understand what services are and are not covered."

Considering that prescription medication is one of the fastest-rising costs for patients and the Medicare system, the AAFP urged CMS to consider copayments -- not coinsurance -- as the standard for cost sharing for patients who have chronic conditions that require continual medication.

Use of prescription medication may offer insight into how much risk an insurer acquires with each patient, but it does not provide a complete picture because the same medication can be used for low- and high-cost conditions, Filer cautioned. She advised CMS to use prescription data for identifying risk only in tandem with patient diagnosis information.

"The AAFP believes CMS should institute effective data sharing mechanisms for obtaining the actual patient diagnoses from a patient’s medical home that will not increase the administrative burdens on physicians," she wrote.

The proposed rule also includes steps to level the playing field between insurers entering a market and those that have been participating for several years. Companies that are new to a market would have a full year before being required to report individual patient data, providing time to capture a more accurate picture of their patient populations. Several insurers that began participating in 2014 were not providing a full picture of their costs in order to reduce the rebates offered to beneficiaries.

The AAFP asked CMS to apply this same method of calculating risk for patients who recently obtained insurance and do not have a complete medical history, a move that would assist physicians when they are reporting outcomes. Another measure in the proposal that would benefit patients calls on new plans in a market to offer coverage for a full calendar year. Previously, there was no minimum time commitment. The AAFP supports this proposal, noting it is consistent with commercial insurance standards.

"Ultimately, the AAFP wants more choices available for patients, who too often raise concerns to their family physician about plans, premiums, benefits and seeing the doctor they want to," Filer wrote.

Related AAFP News Coverage
FPs Report Patients Realizing Health Benefits of ACA Coverage
Insurance Hassles, Not Patient Volume, Among Hurdles Seen to Date

(7/16/2014)


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