Patient Access to Primary Care in Marketplace Plans Critical, Says AAFP

March 07, 2014 12:44 pm News Staff

The AAFP takes every opportunity to remind CMS of the value of primary care for all Americans and the Academy's commitment to its own "Health Care for All" policy. Case in point, the AAFP recently was made aware of draft letter published online by CMS( for the benefit of "issuers" or those entities looking to offer qualified health insurance plans in a federally facilitated marketplace in 2015.

The draft letter -- a federal document similar to a CMS draft proposal written in the rule-making process -- offered operational and technical guidance to issuers to help them successfully participate in health insurance marketplaces as part of the Patient Protection and Affordable Care Act.

One small paragraph on page 38 of that 51-page CMS letter caught the AAFP's attention and prompted a Feb. 24 letter to CMS Administrator Marilyn Tavenner.(2 page PDF)

AAFP Board Chair Jeff Cain, M.D., of Denver, pointed out the AAFP's interest in section seven of the document, which states: "CMS is considering whether to require through rule making that all plans, or at least one plan at each metal level per issuer (referring to marketplace bronze, silver, gold or platinum health insurance plans), cover three primary care office visits prior to meeting any deductible."

CMS went on to say it encouraged qualified health plan issuers in the federally facilitated marketplaces "to cover three primary care office visits prior to meeting any deductible."

Cain reiterated the Academy's support for Affordable Care Act, the expansion of health care access for Americans and a more robust health care delivery system based on primary care. But he also called for inclusion of even stronger language before CMS posts the final version of its letter to issuers.

"Rather than only encouraging QHP (qualified health plan) issuers to cover three primary care office visits prior to meeting any deductible, the AAFP instead urges … (CMS) to consider requiring this benefit within the final 2015 call letter," said Cain.

He pointed out that the AAFP's "Health Care for All" policy states that primary care provided by or through the patient-centered medical home should be available with no financial barriers -- meaning no patient copays or deductibles -- and should include prenatal care, well-child care, immunizations, basic mental health care, evidence-based preventive services, chronic care management and hospice care.

Cain said the three-visit requirement aligned with the AAFP's patient-centered medical home model of care and would allow the care team to "foster a relationship with the patient," and increase patient adherence to any treatment and follow-up plan.

He pointed out that patients without health insurance often have ailments that go untreated. "The three-visit requirement gives them an appropriate incentive to see their primary care physician in their medical home to address those ailments and thus prevent costlier care down the road," said Cain.

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