As open enrollment for health insurance exchanges begins this weekend, physicians have adopted new policy aimed at addressing inadequate provider networks so patients have access to the care they need and the physicians they rely on.

The new AMA policy, which is part of a new report by the AMA Council on Medical Service, calls for health insurers to make changes to their provider networks before the open enrollment period gets underway each year. Implementing changes to provider networks at this time will help prevent patients from being stuck with plans that drop their physicians after they already have enrolled.

The policy also reiterates the need for health insurers to provide patients with an accurate, complete directory of participating physicians through multiple media outlets. These lists also should identify physicians who are not accepting new patients.

“Patients deserve to have an honest look at their coverage options—including the physicians, hospitals and medications they will have access to as well as cost-sharing—so that they can make an informed choice,” AMA President Robert M. Wah, MD, said.  

Inadequate networks could lead to interruptions in patient care, delayed care and undue harm, Dr. Wah said. “They can also prevent patients who are newly insured from being able to access the physicians that suit their needs in a timely manner.”

Other provisions of the new policy include:

  • Promoting state regulators as the primary enforcers of network adequacy requirements. These regulators can ensure compliance with state network adequacy laws and regulations that are intended to make sure patients have access to adequate provider networks throughout the plan year.
  • Calling for insurers to submit quarterly reports to state regulators. These reports should provide data on several measures of network adequacy, including the number and type of physicians who have joined or left the network, the provision of essential health benefits, and consumer complaints received.
  • Calling on insurers to treat patient visits to out-of-network physicians the same as in-network visits if the plan’s provider network is deemed inadequate.
  • Supporting regulation and legislation that require out-of-network expenses to count toward a patient’s annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or is forced to go out of network as a result of network inadequacies.

“Patients who need to seek care out of network should not be punished financially,” Dr. Wah said. “If patients find themselves in networks that are deemed inadequate, there should be adequate financial protection in place to ensure they can access the care they need and deserve.”

The new policy is part of the AMA’s ongoing efforts to secure patient access to adequate networks of care. Nationally, the AMA has urged the Centers for Medicare & Medicaid Services to strengthen network adequacy requirements for health insurance plans being sold through the health insurance exchanges. The association also has advocated for transparency in Medicare Advantage plans to ensure patients are aware of any changes to physician networks before the open enrollment period.

On the state level, the AMA has created an Affordable Care Act state implementation toolkit that contains four model bills addressing tiered and narrow networks and access to accurate provider directories. The AMA also has worked with state medical associations to support state legislation requiring out-of-network transparency and to implement more stringent network adequacy standards than those outlined in federal requirements.

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