US Law Prods States to Revisit Health Care Rules

Prompted by the health care overhaul law, several states are updating their rules for insurance networks to better reflect who is covered and how people shop for and use their benefits.

Laws governing health insurance vary, but states generally try to ensure that health plans give residents reasonable access to a sufficient number of primary care and specialty physicians, said Tyler Brannen, a health policy analyst for the state of New Hampshire. Yet that aim hasn't kept up with changes in how and where people access health care, he added.

For example, nurse practitioners and physician's assistants now provide a significant share of primary care, and many consumers head to urgent care clinics instead of scheduling office visits, he said. And the current focus on hospitals ignores the reality that virtually every service provided during a short-term hospital stay is now available in other settings, including ambulatory surgical centers.

"There's going to be an emphasis on types of services, versus types of providers," he said of the new standards being put in place.

New Hampshire recently began working to revise its 2001 rules, and while its first step in that direction came after a consumer challenged them under the Affordable Care Act, Brannen said he realized years ago that the standards were outdated. Washington state just implemented new regulations, and discussions are underway in several others, including Arkansas, Minnesota and California.

Also changing is how many people have insurance and who makes up that group, with previously uninsured residents gaining coverage through the health overhaul law and the expansion of Medicaid, which in New Hampshire will involve using federal money to buy private health coverage.

"We're now talking about people with different health care needs, and different abilities to travel to providers," Brannen said.

Similar discussions are playing out elsewhere, said John Weis of Quest Analytics, a Wisconsin company that provides software and consulting services for health plans, employers and government agencies seeking to measure network adequacy.

"States are saying, 'Boy, you know what? The process I had in place wasn't really sufficient,'" he said. "What you've witnessed over the last six months is consumers saying, 'Hey, my provider's not in the network, my hospital's not in the network, these networks are so skinny, there's no access to care,' because there weren't any rules that prohibited plans from doing that."

Given the relatively quick implementation requirements of the health overhaul law, however, most states did not have sufficient time to revamp their process, Weis said. Regulations vary by state, and states are taking different pathways to update them. Legislative approval is required in some states, while in others, insurance departments have the authority to make changes.

Anna Odegaard is head of an advisory committee representing consumers and small businesses in Minnesota. She believes the standards adopted when the state created its marketplace, MNsure, aren't strong enough because they only focus on how far patients live from providers and not on whether those providers are actually accepting new patients.

Her committee has heard complaints from providers who believe their specialties are not well represented in the marketplace and from navigators who helped people sign up for coverage. Many new enrollees had no idea whether their doctors would be included until after they signed up, she said.

"The conversation right now is: How do we get MNinsure or the Department of Health to do the data collection to substantiate that there really is a problem, so we can come back around with solutions?" she said.

Washington state's insurance department began developing a new network adequacy rule in September, and the approved changes took effect Monday. The new regulation was designed to give consumers more information about the networks, according to Insurance Commissioner Mike Kreidler. In a statement, he said many consumers were upset to find their health plan no longer included their trusted doctor or hospital.

"The Affordable Care Act increased benefits, but it also expanded the role consumers are expected to play when shopping for health insurance," he said.

The previous network rules dated back to 1998 and hadn't been modified since 2003. Under the rule, insurers must supply detailed geographic information illustrating how their networks meet the needs of all their enrollees. It doesn't prohibit narrow networks but requires all networks to guarantee timely and adequate access to care.

"I also want health insurers to innovate, especially if it helps keep costs down for consumers, but innovation cannot be at the expense of a consumer's ability to access care," Kreidler said.

Balancing access with affordability, while increasing transparency for consumers, also are key goals in New Hampshire, Brannen said.