On November 12, 2014, the National Association of Insurance Commissioners (“NAIC”) released a draft model law updating the NAIC’s Managed Care Network Adequacy Model Act.  The NAIC regularly creates model laws to serve as templates to assist federal and state lawmakers and regulators in drafting insurance laws and regulations. The NAIC noted that its network adequacy model law, which has remained unchanged since it was originally introduced in 1996, needed to be updated to address recent changes in the insurance marketplace.  In addition, the controversy over the use of narrow provider networks by product issuers on the 2014 marketplace exchanges in each state established under the Affordable Care Act (the “Exchanges”) led the Centers for Medicare and Medicaid Services (“CMS”) to examine the adequacy of provider networks more closely for Exchange plans in 2015.  Because of the NAIC’s efforts to update its model law, CMS recently stated that it is waiting on the NAIC to finish its work on the draft model law before “proposing significant changes” to its network adequacy policy for products offered on the 2016 Exchanges.[1] Accordingly, the model act may have far reaching implications for health plans and provider networks.

The draft model law includes several key changes to the existing NAIC model.  The draft model law drops references to “managed care plans” in favor of using “network plans,” with the drafting notes stating that the term “network plan” is intended to be defined more broadly, to include any network-based qualified health plans sold through Exchanges, preferred provider organizations, and health maintenance organizations.  In addition, while the original model law required issuers to ensure and maintain adequate patient access to providers, the draft model law includes a new requirement for issuers to submit access plans to state regulators.  States are given the option to either require approval of the access plan by the insurance commissioner, or simply require the access plan be filed with the state. 

The draft model law also includes several new criteria to be examined in determining the sufficiency of a provider network, including geographic population dispersion and new health care delivery system options such as telehealth and telemedicine.  Provider directories are also addressed by the draft model law, with a new requirement that online provider directories be available and updated at least monthly.  Print copies of provider directories must be available upon request, as well as accessible versions of the directories for individuals with disabilities or limited English language proficiency.

As noted above, the NAIC’s model laws are often adopted by legislatures and federal and state regulators, and CMS has stated it will revise its own network adequacy laws based on what the NAIC recommends.  Accordingly, it is important for any insurer that utilizes provider networks and for the provider networks themselves to understand how these provisions may impact them.  In addition, these provisions are not final; the NAIC is accepting comments until January 12, 2015, on the draft model law. 

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ENDNOTE

[1] Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016 (proposed Nov. 26, 2014) (to be codified at 45 CFR pts. 144, 146, 147, et al.).