New ACA Rules Could Require Broader Provider Networks


"If you like your doctor, you can keep your doctor." President Obama repeated this assurance to the American public numerous times, and the statement was prominently featured on the White House web site prior to and after adoption of the Affordable Care Act in 2010.  

The Obama administration is developing regulations to address the concerns of consumers who say the Affordable Care Act ("ACA") has restricted their ability to choose doctors and hospitals, without incurring sizeable medical bills for out-of-network services.

In order to create health insurance plans with lower premiums, so as to be more affordable and more attractive to individuals shopping for insurance on the ACA-mandated, newly-created insurance exchanges, many insurers have established plans with narrower provider networks, giving plan members fewer doctors and hospitals to choose from. Smaller networks allow the insuror to exercise greater control over provider charges and to limit their networks to only the highest quality providers, enabling them to offer high-value plans with lower premiums. The "flip side" of this trend, however, is that patients have fewer doctors and hospitals to choose from, and may incur substantial medical expenses if they receive services from doctors or hospitals which are not part of the network.

To address the concerns of patients who say that many health plans offered under the ACA unduly limit their choice of providers, CMS is developing new requirements which will require health plans to offer broader provider networks. Federal officials have said the new requirements will be similar to the standards currently used to determine whether Medicare Advantage Plans have a sufficient number of doctors and hospitals in their networks. Federal standards specify the minimum number of primary care doctors and specialists which must be included in the network for a Medicare Advantage Plan, based on population in the area served by this Plan, population density, and other factors. Medicare also establishes maximum travel time and distance criteria.  Similar travel standards are already in place for Florida HMOs.

A number of insurers have opposed detailed federal rules, arguing that consumers should be able to choose more affordable, high-value plans, with narrower provider networks.


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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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