The Association for Community Affiliated Plans (ACAP) respectfully submits comments regarding the Draft Proposed Revisions to the Managed Care Plan Network Adequacy Model Act.
ACAP is an association of 59 not-for-profit and community-based Safety Net Health Plans (SNHPs) located in 24 states. Our member plans provide coverage to approximately 12 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP) and Medicare Special Needs Plans for dually-eligible individuals. Nationally, ACAP plans serve roughly onethird of all Medicaid managed care enrollees. Seventeen of ACAP’s Safety Net Health Plan members have elected to offer qualified health plans (QHPs) in the Marketplaces in 2015.
Summary of ACAP’s Comments
The draft Network Adequacy Model Act covers a wide array of topics related to network adequacy; we have opted not to respond to all of them, but have restricted our comments to those issues that currently concern us most. The Model Act will be very helpful to states and HHS as they develop their own network adequacy requirements; we very much appreciate the effort that the Network Adequacy Model Review (B) Subgroup has put into the draft thus far. That said, we have identified a few sections of the draft Act for which are vague. Because of the attention the Act has and will continue to receive, it is critically important that these areas are clarified and reflect the complicated nature of provider data.
ACAP’s proposed language listed below is explained in greater detail later in the letter:
Carrier/Provider Contract Termination and Member Notification- 6L(1)(d): In instances where a provider does not notify the health carrier of their termination, the health carrier is responsible for making a good faith effort to notify covered persons being seen by the provider on a regular basis within thirty (30) days, after learning of and confirming the provider’s termination.
Continuity of Care Provisions due to Active Treatment and Special Circumstance- 6L(2)(b)
(ii): A health carrier shall agree to extend its obligation to reimburse the treating physician or provider for active 2 treatment at the in-network rate if: (i) The health carrier agrees that a condition for which ongoing treatment is being provided is part of a short-term agreement for enrollees undergoing active treatment; and
(ii) The contract termination was not “for cause.”
Special Enrollment Period due to Provider Directory Inaccuracies- 6L Drafting Note: ACAP recommends that the drafting note be deleted.
Monthly Update to Provider Directories- 8A(2): The health carrier shall update each network plan provider directory at least monthly after making a good faith effort to verify changes and shall be offered each provider directory in a manner to accommodate individuals with limited-English language proficiency or disabilities.
Searchable Provider Directory- 8D: The requirement that the online directory be searchable for the features described in 8C shall go into effect two (2) years after this legislation is signed into law.
Health Care Professionals’ Affiliations- 8C(1)(a): Hospital affiliations in the health carrier’s network;
Health Care Professionals’ Affiliations- 8C(1)(b): Medical group affiliations in the health carrier’s network;
Improving the Accuracy of Provider Directories- Drafting Note Proposed Language: In addition to requiring health carriers to update their provider directories at least monthly, to help improve the accuracy of the directories, states could consider the following:
1) a requirement that health carriers in some manner, such as through an automated verification process, contact providers listed as in network who have not submitted claims within the past six months for primary care providers and twelve months for specialists or some other time frame a state may feel is appropriate, to determine whether the provider still intends to be in network;
2) a requirement that health carriers internally audit their directories and modify directories accordingly based on audit findings to access: a) whether their contact information is correct, b) whether they are really in the plan’s network; and c) whether they are taking new patients; and 3) closely monitoring consumer complaints.
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