[powerpress]
The implementation of the Affordable Care Act has had an impact on provider and patient interaction. Two policy staff discuss how narrow networks and the cost of marketplace coverage can become barriers for patients to receive care.
Transcript:
Matt: Welcome to Healthcare in Policy and in Practice, the health policy update from America’s Essential Hospitals. Today is July 2 and my name is Matt Buechner. For today’s podcast, I am joined by my colleague and policy analyst, Zina Gontscharow. Today, we’ll discuss health insurance marketplaces and provide an update on key policy issues to watch for in the current and upcoming year.
First, let’s talk about health insurance marketplaces. At the most basic level, when we talk about “marketplaces” and “exchanges” we are actually talking about the same thing – these terms are interchangeable. The Affordable Care Act, known as the ACA, gave each state the opportunity to create a website where insurance companies could sell health insurance plans to the people of that state. If the state decided that they did not want to create their own exchange, they could opt to use an exchange set up and administered by the federal government.
So, the next question that you might be wondering is why would someone use the exchanges, in the first place? Zina, why are people using these exchanges?
Zina: Let me step back, people are using the exchanges because the Affordable Care Act, or ACA, has a requirement, known as the individual mandate. That mandate requires every person in the United States to be covered by health insurance.
The exchanges have been created as a one stop shop to compare and purchase insurance coverage. So, for individuals, who do not receive insurance coverage through their employees, or are self-employed, the exchanges allow these individuals access to affordable health insurance coverage options, can compare plans, and choose the right option for their needs.
Additionally, for lower income populations, the ACA has provided for subsidies to help those individuals afford their insurance premiums.
Matt: So, Zina, we have this population that likely won’t be able to afford their premiums, or the amount that a person pays an insurance company for health insurance. Lately there has been discussion around whether a provider or non-profit foundation can subsidize these premiums for patients. What have we heard from CMS on the topic?
Zina: CMS has had a number of things to say about premium assistance. CMS has received a number of questions regarding whether qualified health plans, or QHPs, offered on the exchanges are required to accept premium assistance from certain groups.
CMS issued an FAQ in November 2013 to try to address this issue. This FAQ encouraged QHP issuers not to accept third-party premium assistance from hospitals, other healthcare providers, and other commercial entities due to concerns that such practices could skew the insurance risk pool and create an un-level field in the exchanges.
CMS then released an additional FAQ in February of this year. This FAQ was issued to clarify that the previous November FAQ was not intended to discourage QHP issuers from accepting third-party premium and cost-sharing payments made by Indian tribes, tribal organizations, urban Indian organizations, as well as by state and federal government programs, such as the Ryan White HIV/AIDs Program. However, the language regarding the foundations was omitted.
CMS then followed up the interim final rule with a letter stating that QHPs were not prohibited from accepting payments from not-for-profit foundations on behalf of enrollees in the exchange.
So, at this point, we are waiting to see what CMS will finalize when they issue the final regulation on this issue.
Matt: Clearly, premium assistance would be great for the patient being able to afford health insurance, but what do advocates of provider-sponsored premium assistance say about benefits?
Zina: Provider sponsored premium assistance is an opportunity to strengthen the overall success of the exchanges and facilitate the ability for patients who really need affordable health care, to access it. Countless studies have shown that having stable health insurance coverage and access to providers does nothing but improve health outcomes. Overall, those that are covered are likely to seek the preventative care that they need, which saves money in the long run, as patients are receiving care before their health conditions worsen.
Additionally, the more people we have enrolled in the exchanges – the stronger the exchanges become. Simply put, a larger the pool of consumers in the exchange encourages price competition which is never a bad thing. An active, competitive exchange attracts plans, which further increases the options for consumers.
Matt: So, you just spoke briefly about plans that are being offered on the exchanges. Can you talk a little more about that, particularly about some of the issues facing patients and providers?
Zina: Let me start first with providers. So, providers have faced some issues with contracting with the QHPs being offered on the exchanges. What we’ve seen is that QHPs have using what we call narrow networks. Narrow networks are, depending on the region, where 30 to 69 percent of the largest hospitals are not participating in the QHP. Taking it a step further, some QHPs are utilizing ultra-narrow networks, where 70 percent of the largest 20 hospitals in a QHP plan area are not participating with the QHP.
So, what does that mean for patients? Unfortunately, what that means is that in some instances existing provider/patient relationships may be broken. If a provider is not participating with a patients’ QHP, the patient will either have to pay out-of-pocket costs to see that existing provider or establish a relationship with a brand new one.
Matt: These narrow networks remove certain providers from plans, causing patients to spend more money out-of-pocket to go to their regular provider. For instance, if you want to continue seeing your psychiatrist, because you’ve built up rapport, trust, and a relationship with them, but they have been excluded from your plan, you will have to pay out-of-network costs. Given the financial implications for patients and providers, is CMS providing any guidance on this issue?
Zina: In the case of the essential community providers or ECPs – which are hospitals, children’s hospitals, federally qualified health centers, Ryan White HIV/AIDS clinics and other community providers relied on by vulnerable patient populations. QHPs are required to contract with a certain number of these providers in their plan area. CMS has provided guidance to QHPs on this requirement through yearly issuers’ letters. Initially, CMS set the requirement that QHPs must contract with at least 20 percent of available ECPs in their service area. In the most recent issuers’ letter, for fiscal year 2015, CMS increased the requirement to 30 percent. Only time will tell how much more CMS will get involved in this issue and really push for the plans to contract with area ECPs.
Matt: As the data from this first open enrollment period begins to roll in over the next few months and the plans offered by insurers through the exchanges for the 2015 open enrollment cycle are released, understanding how premium assistance and narrow networks impact patients and providers will give us an additional lens to evaluate success.
For more health policy news and information on topics we discussed today, please visit the Action tab or search bar on the America’s Essential Hospitals homepage at www.essentialhospitals.org. Thank you for listening to today’s edition of Health Care in Policy & in Practice and thank you to Zina Gontscharow for joining us today. My name is Matt Buechner, join us next month for another health policy update.