195. Health Insurance
195.997 Grace Periods: Policyholders Receiving Advance Payment Tax Credits
The Colorado Medical Society supports the following Notice Requirements for Health Plans
- Timing of notice to physician or provider of Grace Period status.
- When a physician or other health care provider or a representative of the physician or other health care provider requests information from a carrier regarding an Enrollee’s eligibility, an Enrollee’s coverage or health plan benefits, or the status of a claim or claims for services provided to an Enrollee, or reports a claim in a remittance advice, and the request for service is for a date within the second or third month of a grace period, the carrier shall clearly identify that the applicable Enrollee is in the Grace Period and provide additional information as required by this regulation.
- The carrier must provide this notice through the same medium through which the physician, other health care provider or representative sought information from the carrier concerning the Enrollee’s eligibility, coverage or health plan benefits, or related claims status, or normally receives claim remittance advice information.
- The information provided about the Enrollee’s Grace Period status shall be binding on the carrier.
Specific notice requirements.
- If the carrier informs the physician or other health care provider or a representative of the physician or other health care provider that the Enrollee is eligible for services, and does not inform the physician or other health care provider that the Enrollee is in the Grace Period, that determination shall be binding on the carrier, and the claim(s) for services rendered shall be paid by the carrier.
- This binding determination shall further preclude the carrier from seeking to recoup payment from the physician or other health care provider.
- If the carrier informs the physician or other health care provider that the Enrollee is in the Grace Period, then the carrier must provide further notification pursuant to Section as outlined below.
Contents of notice. The notice to the physician or other health care provider shall include, but not be limited to the following:
- Purpose of the notice;
- The Enrollee’s full legal name and any unique numbers identifying the Enrollee;
- Name of the carrier;
- The carrier’s unique health plan identifier;
- The specific date upon which the Grace Period for the Enrollee began, and the specific date upon which the Grace Period will expire.
The carrier shall include in a conspicuous manner on the Exchange and the carrier web site, an explanation of the action the carrier intends to take, both during the Grace Period, and upon the Grace Period’s exhaustion for the Enrollee and the physician or other health care provider, including further options for the provider. This shall include:
- Whether the carrier will pend any claims of the physician or other health care provider for services that the physician or other health care provider furnishes to the Enrollee during the Grace Period;
- A statement indicating that, should the carrier indicate that it will pay some or all of the claims for services provided to an Enrollee during the Grace Period, whether and how the carrier will seek to recoup claims payments made to physicians or health care providers for services furnished during the Grace Period.
(BOD-1, AM 2014)
195.998 Regulation of Health Plan Network Activities
The Colorado Medical Society supports enhanced beneficiary/provider protections related to transparency and quantitative standards for network adequacy of health insurance plans. CMS supports the following principles:
- Stronger transparency requirements including accurate provider directories; clear information about patient cost-sharing requirements for both in-network and out-of-network care; public disclosure of provider selection standards; and public disclosure of insurers’ network adequacy plans, without allowing information to be considered “proprietary” and off limits for the public;
- Establishment of quantitative standards for measuring network adequacy, moving away from provisions that allow insurers to refer to “any reasonable criteria” to prove network sufficiency, and encourage that quantitative standards be established that apply to all plans;
- Active regulator evaluation and approval, rather than insurer self-attestation of network adequacy and deference to accreditation;
- Incorporation of quality and other data safeguards that will ensure the integrity of data being used to evaluate physicians and other providers and protect them and their patients from network decisions based solely on cost; and
- Clear definitions and designations for “narrow,” “high quality,” “high value,” and “high performing” networks, in order to prevent patient confusion.
CMS opposes the disruption in an existing physician-patient relationship caused by plan changes to provider networks in the middle of a plan year. When an insurer terminates a physician’s participation agreement without cause, if both parties agree, the physician and patient should be allowed to continue the relationship for the remainder of that plan year as if the physician was still part of the network.
CMS will convey support of these principles to the Colorado congressional delegation and encourage their support of legislation which upholds these principles.
CMS will engage with the Colorado division of insurance and other stakeholders to evaluate the adequacy of current standards for health plan networks and notification procedures when providers are dropped from those networks.
(RES 1-P, AM 2014)