🔒CT expands scrutiny of health plans

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Connecticut is taking a significant step to improve transparency of insurers' medical provider networks, a move doctors and regulators say is necessary as consumers face more complexities in where they can choose to receive care.

A new set of wide-ranging regulations give state regulators the power to determine whether or not a commercial health plan's network of medical providers offers consumers adequate access to health services.

The state Insurance Department also will assess for the first time ever the accuracy of insurers' published physician directories.

The rules address longstanding sources of friction between doctors and insurers. Doctors say there is a need for greater transparency over network adequacy, especially as health plans increasingly adopt “tiered” networks, which incentivize patients to visit certain medical providers over others.

Doctors have been skeptical of the tiered approach, arguing they don't always understand why an insurer places them in one tier instead of another (Connecticut's new law requires an explainer). They also argue that some tiers may not offer an adequate mix of specialists close to patients and who are also taking prompt appointments.

Insurers, meanwhile, have said splitting providers into tiers based on perceived value or other metrics has been an effective strategy to control healthcare costs by encouraging patients to seek care from higher-quality and/or lower-cost providers.

“It is important for policymakers to appreciate that broad access and affordability don't always go hand in hand and that high quality coverage can be afforded through structured provider networks,” the Connecticut Association of Health Plans said in testimony on the new regulations last year.

Insurance Commissioner Katharine Wade said the new regulations, which took years to hash out, represent a compromise between insurers and doctors and align with standards issued in late 2015 by the National Association of Insurance Commissioners (NAIC), of which she is a member.

Connecticut is among the first states to adopt the bulk of the NAIC provisions.

Insurers in the state have opposed past legislative attempts to regulate network adequacy, but while the new rules increase state oversight, they likely won't do much — at least for now — to stop the spread of tiered networks.

”I think this is an area that needs increased focus,” Wade said in a recent interview in her Hartford office. “We need to make sure that consumers fully understand the products they're buying and that the companies are providing networks that give people adequate access.”

The effect of the regulations remains to be seen. Doctors say they are watching keenly, wanting to see improvement in directories and whether or not Wade determines if any in-state networks are insufficient.

“This, compared to what we had, is a really good additional step forward,” said Dr. Jeff Gordon, president of the Connecticut State Medical Society and a practicing oncologist and hematologist with Hartford HealthCare in Waterford. “We're going to see how this actually works. We can talk in a year about the negatives.”

Wade and her staff — which includes an examiner who specializes in network adequacy — are in the process of evaluating detailed reports submitted by nearly 50 health insurers.

Wade is now required to annually assess the adequacy of each plan network. It wasn't clear as of press time exactly how long the first round of decisions would take.

“We'll be looking at [the reports] and if there's adjustments that need to be made as a result of our review, then we'll be asking companies to do that,” Wade said.

Wade said she will be paying close attention to behavioral health providers included in plans because Connecticut has a shortage of those practitioners, according to federal data.

The reports from insurers were originally due in mid-October, but the Insurance Department asked a number of carriers to submit additional information, which pushed the due date to Jan. 23.

Medical Society CEO Matt Katz said he is enthusiastic about the new rules overall and credits Wade's support as key to getting a bill through the legislature last year. But he's disappointed that the network reviews were not complete by the law's Jan. 1 effective date.

“We still don't know whether or not these plans have adequate networks and what needs to be adjusted as a result,” Katz said. “That's a little disconcerting.”

Directories

The new regulations aim to give insurance customers clearer information about their health plans by requiring doctor directories to be updated at least monthly. There will also be periodic audits.

The Insurance Department can enforce corrective actions and fines as high as $15,000 per violation.

Physician listings must include such information as speciality, office locations, group and facility affiliations, languages spoken and whether doctors are accepting new patients. Key for doctors who advocated for the rules is a provision that says insurers must indicate which doctors are in specific network tiers.

An outdated or inaccurate directory can cause headaches. And it can sometimes cause a patient to seek care from an out-of-network doctor, resulting in higher-than-expected charges, Katz said.

Network adequacy

Network adequacy is defined by the National Conference of State Legislatures as “a health plan's ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all healthcare services included under the terms of the contract.”

The federal government has crafted adequacy rules for Medicare Advantage and Obamacare plans. The regulations now taking effect in Connecticut are similar in many ways.

Under previous Connecticut law, insurers were required to attest they were accredited by one of two accrediting entities that monitor network adequacy, but the state played no role in that oversight.

Doctors weren't satisfied with that being the sole requirement, as accreditation involves more than just network adequacy. If a health plan failed the adequacy standards but did well in other areas, it would still pass, Katz said.

Wade said the accreditors — National Committee for Quality Assurance and URAC — have robust and regularly updated standards, but the new rules allow the state to check their work and make its own decision.

A spokesman for the Connecticut Association of Health Plans did not respond to requests for comment.

The law gives Wade wide latitude in how she reviews networks. There is no specific formula she's mandated to use, but her review could include such metrics as provider-patient ratios, geographic availability and wait times.

Doctors have pushed for specific metrics to be applied and Katz said his organization intends to pursue further legislation to make that happen.

Asked if she would be in favor of stricter rules, Wade said she would need to see a specific proposal first.

“The law just went on the books, so we need to give it a little bit of time to work,” she said, adding that her office will listen to any complaints.

Gordon, the oncologist, said he hopes the new rules lead to noticeable improvements in the year ahead.

He said he has increasingly had trouble referring patients to other in-network doctors. Some might be far away, while others may not have openings for several weeks or more. That, to him, is inadequate.

Insurer directories can also come into play when referring patients. Since Gordon's staff uses them to help determine where to send patients, inaccuracies can cause delays and other issues, he said.