Health & Spirit

Trump administration: Let states decide if health plans have enough doctors

Michael Ollove, on

Published in Health & Fitness

Officials in some states using the federal exchange say they are capable of reviewing network adequacy without federal help. "Functionally, what we saw in the prior administration was a lot of duplication," said J.P. Wieske, the deputy insurance commissioner in Wisconsin, one of the states using the federal exchange.

Jessica Altman, the acting insurance commissioner in Pennsylvania, another state that uses the federal exchange, said her state already vigorously enforces network adequacy, though she didn't object to federal regulation as well. "For us, the federal oversight was a second check, and that's good to have there."

Some critics acknowledge that states are better positioned to regulate network adequacy because officials understand the local insurance markets. Still, they worry some states don't have regulations in place to protect consumers, or the necessary staff to take on the labor-intensive oversight.

"Our concern is that the Trump administration is rolling back a lot of the assurances consumers should be able to rely upon without keeping a minimum of standards that would protect them," said Betsy Imholz, a health policy expert at Consumers Union, the research and advocacy arm of Consumer Reports.

Many states, even among those that use the federal exchange, have long regulated network adequacy, but they did so to varying degrees. Some only reviewed HMOs. Some examined network adequacy only at the point an insurer first applied for licensing. Some relied on claims made by insurers without further investigation.

But some states do not regulate network adequacy. In that case, under the Trump rule, insurers can seek accreditation from an independent nonprofit approved by the U.S. Department of Health and Human Services. Critics argue, however, that there is nothing to guarantee that those accreditation agencies have network adequacy standards themselves or seek information beyond what an insurer provides.

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"Accreditation is basically self-regulation," Imholz said.

In any case, in a subsequent release in November, the Trump administration determined that all states are capable of oversight themselves, although the administration does not specify what makes a state capable.

Tennessee is one of those states that says it will rely on accreditation, said Kevin Walters, communications director for the state's Department of Commerce and Insurance. Tennessee laws on network adequacy apply only to HMOs and not the preferred-provider plans sold on the exchanges. But, Walters said, the state is comfortable with the accreditation method, since that's how Tennessee oversaw network adequacy in 2014 and 2015, before the Obama administration established standards.

The Affordable Care Act added national standards, such as the limits on the time and distance patients should have to travel to see their providers and the minimum ratio of doctors and specialists to enrollees in a plan. Some also set maximum times that patients should have to wait for appointments and also require that insurers keep their rosters of providers current. States on the federal exchange were free to adopt their own rules, but health plans in those states had to comply with minimum federal thresholds.


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