02.29.2016 / Press Release

New CMS Rule Promotes Standardized Plans but Falls Short on Network Adequacy

Washington, D.C. – A new rule, announced today by the Centers for Medicare and Medicaid Services (CMS), takes some significant steps in improving the quality of health insurance coverage available to consumers in the federal marketplace beginning in 2017. Specifically the new rule: encourages – but does not require – insurers in the federally facilitated marketplaces to offer standardized plans across the bronze, silver and gold levels, with federally defined cost-sharing amounts for various services. Under these plans, consumers will only be responsible for copayments when they need doctor visits and most prescription drugs.

Lost in the final rule was a proposed requirement that states in the federal marketplaces set clear, measurable standards on what defines health plan “network adequacy.” The proposed rule required states to set standards for the numbers and types of health care providers in the plan (a “provider to enrollee ratio”) or the time and distance a patient must to travel to get care. CMS would have implemented standards for non-compliant states.

Following is the statement of Joe Ditré, Senior Director of Enterprise and Innovation at Families USA, regarding the new rule:

“We applaud CMS for creating standardized plans. They will help consumers pay for a number of services, like a routine doctor’s visit, even if they have not reached their deductible, and make it easier for consumers to make “apples-to apples” comparisons among plans. We urge all insurers in the federal marketplace to make these options available to consumers.

“However, we are very disappointed that CMS did not go forward with measurable network adequacy standards for federal marketplace states. They would have provided a meaningful and much-needed improvement to ensure the consumer gets what they pay for in an insurance plan. If a plan doesn’t have enough providers, or they are too far away, consumers can’t get the true benefits of health insurance. We urge states to take swift action to implement quantitative network adequacy standards. We hope to see federal policymakers take additional steps to address this problem as well so that all consumers have access to the providers they need, regardless of where they live.