The Association for Community Affiliated Plans, Alliance of Community Health Plans, America’s Essential Hospitals, AHIP and the Federation of American Hospitals are asking CMS to pull back on its proposal to permit non-network plans to receive qualified health plan certification, according to a March 13 letter.
The provision fell under a Feb. 9 proposed rule, which focused on sweeping ACA reforms. QHPs meet federal standards, such as offering essential health benefits and abiding by cost-sharing limits, in order to be sold on the ACA marketplace. Non-network plans issue specific benefit amounts and lack contracted provider networks. Under the rule, these payers would need to prove that enough providers accept their benefits as payment in full. CMS accepted comments on its proposal until March 13.
“All QHP plans offered through the marketplaces should be held to the same regulatory standards to ensure consumers can access care,” the letter said. “Permitting non-network plans to compete alongside network-based QHPs would bifurcate the individual market in ways that threaten its long-term stability.”
The five organizations expressed concerns over distorted risk pools, altered statewide average premiums — which inform risk-adjustment calculations — and a market split based on health status. The letter warned of a possible rise in uncompensated care, considering how hospitals may assume costs of patients who were unclear about their coverage. Adequate provider access was another worry, as a plan will need to be up and running before CMS and the states can confirm this access.
The groups encouraged CMS to clarify what adequate access looks like and how it will be enforced, as well as how consumers will be shielded from balance billing.
While the letter explicitly urged CMS to not move forward with the provision, the organizations said, at a minimum, CMS should delay finalization and issue a request for information to better garner input.
