Model legislation that aims to ensure the adequacy, accessibility, and quality of health insurers’ provider networks does not address a number of concerns voiced by physicians.

The draft legislation , released by the National Association of Insurance Commissioners (NAIC), provides that a managed care plan shall maintain a network sufficient in numbers and types of providers to ensure that all services to covered persons will be accessible without unreasonable delay. Determining adequacy includes – but is not limited to – provider-covered person ratios by specialty; geographic accessibility; waiting times for appointments; hours of operation; new health delivery options, such as telemedicine; and the volume of technological and specialty services available.

The model law applies to all forms of health insurance, including qualified health plans, health maintenance organizations, and preferred provider organizations, J.P. Weiske, chair of NAIC’s network adequacy model review (B) subgroup said in a Nov. 19 webinar hosted by the Alliance for Health Reform.

“One of the biggest decisions we made is it would apply to all forms of health insurance that’s sold,” said Mr. Weiske, who serves as legislative liaison for Wisconsin Insurance Commissioner Ted Nickel.

Once finalized, the model law could be used as a basis for legislation to reform health insurance that could be introduced in any or all state legislatures.

The model legislation arrives amid ongoing physician criticism that many plans being sold on the Affordable Care Act’s insurance exchanges have narrow networks that limit access to primary care doctors, area hospitals, and specialists.

On Nov. 17, more than 115 health care organizations, including the American Medical Association, sent a letter to NAIC calling for network adequacy for patients, greater regulatory oversight in the hands of commissioners, and increased transparency for health insurers. The AMA also passed a new policy at its Nov. 11 interim meeting that supports strengthening the monitoring and enforcement of network adequacy at the federal and state levels.

In their letter, the groups requested that NAIC tackle several critical issues within its model act, recommending that provider networks include a full range of primary, specialty, and subspecialty providers to ensure that consumers have access to all covered services; that regulators actively review and monitor all networks using appropriate quantitative standards; that appeals processes are fair, timely, and transparent; and that the use of tiered provider networks be regulated.

NAIC’s model legislation addresses such issues as provider directories, telemedicine, and the transparency of health networks. It would require that a health insurer post online a current provider directory for each of its network plans and update each directory at least monthly. It also calls on insurers to prepare an access plan prior to offering a new managed care network plan and include:

•How the use of telemedicine or other technology may be used to meet access standards.

•The health insurer’s procedures for making and authorizing referrals within and outside its network, if applicable.

•The health insurer’s process for monitoring and ensuring the sufficiency of the network to meet the health care needs of populations that enroll in managed care network plans.

But the model law does not include standards related to some prevalent concerns by doctors, such as certain appeals, rules related to tiers, and time and distance standards.

For instance, the model does not include provisions about an appeals process for providers unhappy about being excluded from a network or how close geographically a network’s providers should be to patients they are serving. In regard to tiered networks, the model act includes only a sidebar noting that “states may want to pay particular attention to network sufficiency, marketing, and disclosure issues that may arise with respect to certain health carrier network designs, such as so-called tiered networks.” NAIC may revisit the issue of tiered networks at a later date.

“The problem that we had with tiered networks is that they’re relatively new,” Mr. Weiske said during the webinar. “There’s not a lot of similarity between them, but there are some significant regulatory concerns. We decided to essentially put regulators on notice that this is something they should look at.”

Mr. Weiske noted that it made sense to include broad flexibility in the model legislation to allow state regulators to dictate the details that best fit their patient populations and health care systems.

If enacted, the proposed law could end up being very different in different states, added Dr. John J. Reilly Jr., senior medical director of population health for the University of Pittsburgh Medical Center’s health services division and chair of the university’s department of medicine.

“The draft we’ve seen is very broad,” he said during the webinar. “It does not mean the way that states implement it is going to be broad. They can be very specific in their language. For insurers or clinical systems that cross state lines, there will be the potential for having different regulations across their networks because of different implementation of this model draft by different state regulatory agencies.”

Stakeholders have until Jan. 12, 2015, to provide comments on the first draft of the model law. The draft will then move through several NAIC committees before becoming a final model and ready for state legislators to review. 
On Twitter @legal_med