New American Medical Association Policy Works to Protect Patient Choice and Access to Care
New policy addresses issue of inadequate insurance networks and promotes patient financial protections
DALLAS — As open enrollment for the health insurance exchanges gets underway, the American Medical Association (AMA) today adopted a new policy aimed at addressing the issue of inadequate networks to ensure patients continue to get access the care they need. The new policy calls for insurers to make any provider terminations without cause prior to the enrollment period so patients can select health plans that will cover care provided by their existing physicians because today, inaccurate or late revised provider directories are leaving patients stuck with plans that dropped their physicians after they enrolled. However, the new policy allows for new physicians to be added to a network at any time. Additionally, the new policy reiterates the need for health plans to provide patients with an accurate, complete directory of participating physicians through multiple media outlets, which includes identifying providers who are not accepting new patients.
"While plans with narrow networks may have lower patient premiums, some narrow provider networks on the market today provide inadequate access to timely, convenient, quality care," said AMA President Robert M. Wah, MD. "Inadequate networks could prevent patients from being able to see the physicians that they know, trust and depend upon throughout their lives which could lead to interruptions in care, delayed care and undue harm. They can also prevent patients who are newly insured from being able to access the physicians that suit their needs in a timely manner. As enrollment opens for health insurance exchanges, patients deserve to have an honest look at their coverage options — including the physicians, hospitals and medications they will have access to as well as cost-sharing - so that they can make an informed choice."
In addition to calling on insurers to provide up-to-date information on the value of their plans before patients enroll, the new policy also:
- Calls on insurers to treat patient visits to out-of-network physicians the same as they would in-network physicians if the patient's plan is deemed inadequate;
- Supports regulation and legislation to require out-of-network expenses to count toward a participant's annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or is forced to go out-of-network based on network inadequacies;
- Supports the development of a mechanism for patients to file formal complaints about network adequacy with regulators;
- Supports state regulators as the primary enforcer of network adequacy requirements to ensure state network adequacy laws and regulations are followed and patients have access to adequate provider networks throughout the plan year; and
- Calls for insurers to submit reports at least quarterly to state regulators that are publically available to provide data on several measures of network adequacy, including the number and type of physicians that have joined or left the network, data that indicate the provision of Essential Health Benefits and consumer complaints received.
"Patients who need to seek care out-of-network should not be punished financially," said Dr. Wah. "If patients find themselves in networks that are deemed inadequate, there should be adequate financial protection in place to ensure they can access the care they need and deserve."
The new policy is part of the AMA's continued work to ensure patients have access to adequate networks of care. The AMA has urged CMS to strengthen network adequacy requirements for health insurance plans being sold through the health insurance exchanges. We have also advocated for transparency in Medicare Advantage plans to ensure patients are aware of any changes to physician networks before the open enrollment period. On the state level, the AMA has created an ACA state implementation toolkit that contains four model bills on tiered and narrow networks and access to accurate provider directories. The AMA has also worked with state medical associations to support state out-of-network transparency legislation and to call for states to issue more stringent network adequacy standards than what is outlined in federal requirements.
For more information on AMA efforts to address narrow networks, please go to www.ama-assn.org/go/aca.