To assist state legislators and policy makers, AMA has created 6 model bills addressing issues raised by the Affordable Care Act (ACA). The bills address issues including the use of narrow or tiered networks, protection of due process in terminations, maintaining up-to-date provider directories, incorporating quality into physician profiling, recognizing patients’ out-of-network assignment of benefits, expanded grace period notification for physicians and fair contracting.
The ACA is not new, but it continues to have an effect on the evolving health care insurance landscape. The AMA has created 6 model bills to help states address some of the key issues in today’s health insurance marketplace.
AMA ACA Model Bills
Physician Due Process Protections Act: This bill provides physicians the opportunity to challenge termination or denial of participation in a health insurance product or panel. Despite the reason for terminations or denials, such disruptions impact long-standing patient-physician relationships essential to care and affected physicians must be provided a fair process to appeal.
Meaningful Access to Accurate Provider Directories Act: This bill requires insurers to provide accurate, updated provider directories. Such directories are essential to patients when choosing plans, and help regulators and key stakeholders monitor network adequacy.
Physician Profiling and Network Determination Act: This bill requires 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 falls behind cost in determining tiers and networks, but without transparency on both of these factors, it is difficult for patients to make informed choices.
Honoring Patients' Assignment of Benefits Act: This bill requires 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 with a physician now "out of network" under a new exchange plan, or as inadequate networks force patients to go to physicians outside of their network.
Physician Notification of Patients in Health Insurance Exchange Grace Period Act: This bill requires insurers to inform physicians performing an eligibility check whether the patient is in the second or third month of the grace period and how the issuer will handle claims during that time. Failure to do this results in a binding eligibility determination upon the insurer.
Physicians Choice of Health Insurance Products and Panel Act: This bill prevents insurers from requiring physicians who are contracted in one network to be in all of the plans' networks.
Medical Loss Ratio Formula Changes
AMA letter to the National Association of Insurance Commissioners: Comments on potential changes to the definition of "Quality Improvement Activities" in the medical loss ratio formula, Jan. 15, 2016.
Visit the AMA's Affordable Care Act website, which has ACA resources for physicians and patients. For more information or questions, contact Daniel Blaney-Koen, JD, senior legislative attorney at [email protected], or Emily Carroll, JD, senior legislative attorney at [email protected]. They can provide additional documentation, including:
- Physician Due Process Protections Act
- Meaningful Access to Accurate Provider Directories Act
- Physician Profiling and Network Determination Act
- Honoring Patients' Assignment of Benefits Act
- Physician Notification of Patients in Health Insurance Exchange Grace Period Act
- Physicians Choice of Health Insurance Products and Panel Act