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ACA State Implementation

Implementation of the Affordable Care Act (ACA), including health insurance exchanges, continues to require significant state efforts. With the ACA and health insurance exchanges raising new issues, new American Medical Association model legislation can bring clarity to this evolving landscape and protect patients and physicians.

The AMA has created six model bills to help states address some of the key issues raised by health insurance exchanges. Read a summary of the bills or access each bill individually below. Whether introduced as-is, or taken as a framework around which states may customize their own provisions, these bills lay the groundwork for medical society advocacy on state exchange implementation.

Contact Daniel Blaney-Koen, JD, Senior Legislative Attorney, or Emily Carroll, JD, Senior Legislative Attorney, with any questions or for more information. Also visit the AMA's Affordable Care Act website, which has resources for physicians and for patients on the ACA.

Model bills: Narrow and tiered networks

In an effort to hold down costs, health insurers both in and outside the exchanges are employing tiered and narrow network strategies to a degree rarely before seen. While such networks may save some consumers money upfront in their premiums and co-insurance when compared with broader network plans, the AMA has significant concerns.

  • Physician Due Process Protections Act – This would provide physicians full opportunity to challenge termination or denial of participation in a health insurance product or panel. Despite the reason for termination or denial of participation, such disruptions impact many of the long-standing patient-physician relationships essential to patient care, and affected physicians must be provided a fair process to appeal. 
  • Meaningful Access to Accurate Provider Directories Act – This would require insurers to provide accurate provider directories that are updated in a timely manner. Such directories are essential to patients when choosing plans, and to helping regulators and key stakeholders successfully monitor network adequacy.
  • Physician Profiling and Network Determination Act – This would require that all profiling programs, including those used to determine tiered or narrow networks, incorporate quality measures and risk adjustment, while providing physicians the opportunity to review and appeal their profiles. Quality often takes a back seat to cost in the determination of tiers and narrow networks, but without transparency on both of these factors, it is very difficult for patients to make informed choices about their care.
  • Honoring Patients' Assignment of Benefits Act – This would require insurers to recognize patients' assignment of benefits to out-of-network physicians and other health care providers. This is particularly important as patients may wish to continue a relationship with a physician who is now "out of network" under a new exchange plan, or as inadequate networks force patients to receive care from physicians outside of their network.

Network adequacy resources

Insurers offering new plans on health insurance exchanges may be limiting access to care in some areas by significantly narrowing or dramatically tiering provider networks. While these network strategies being employed may not be entirely new, their increased use has generated scrutiny among policymakers and concern among patients and physicians. The AMA's issue brief on network adequacy recommends general principles for policymakers to use when determining how to approach new monitoring strategies and evaluation of networks.

The AMA, working with the state and specialty societies, have been heavily engaged in the National Association of Insurance Commissioners' (NAIC) process to revise its network adequacy model act.  This letter initiated by the AMA and the Children's Hospital Association and signed by more than 100 stakeholder organizations, outlines the priorities for which the AMA and others have been advocating at the NAIC.

Model bill: Grace period

Under the ACA, if patients who receive advance premium tax credits fail to pay their premiums, they enter a 90-day "grace period." During this time, patients continue to have coverage but insurers are able to pend claims to physicians during the second and third months of the grace period. The ACA requires insurers to notify physicians of patients' grace period status when responding to an eligibility verification request, but not in a sufficient manner or to a sufficient degree.

Model bill: Fair contracting practices

Many physicians may be unaware as to whether they are in an exchange network, which is problematic on many levels.  Insurers often claim they are permitted to include physicians in other networks due to "all product clauses" included in physician' contracts.

Medical loss ratio