Recently, the NAIC circulated for public comment two model insurance regulations – one relating to the individual market (both on and off exchanges) and the second relating to small group coverage. Each draft model proposes guidance on a range of important issues including rate setting, enrollment, non-discrimination, essential health benefits, levels of coverage and actuarial value, and rules relating to fair marketing.
So, after rare disease advocates voiced their concerns over the model insurance regulations – no action was taken. We are now concerned the regs will move forward as drafted and the “solution” will be a “drafting note” with concerns of commentators noted. Moreover, we are worried that the current NAIC drafts would erode one of the ACA’s most important consumer protections – the annual limit on out-of-pocket spending. Our ask is that individuals send their comments to each commissioner on the Committee.
Section 14(B) of the individual market model and section 15(B) of the small group model both would permit health insurers to exclude from the annual limit “benefits provided out-of-network.” This is inconsistent with statutory language (see ACA section 1302(c)), and may make out-of-pocket protection more or less illusory in light of well-documented concerns with narrow networks. Additionally, the NAIC’s language is broad enough that it could – in theory – be interpreted by plans to exclude benefits covered through an appeal or exception process. This would be a step backward from current practice.
Comments on the draft models are to be submitted to the commissioners listed on this Spreadsheet: NAIC Commissioner Address LIst
A sample email is included below for your use.
SAMPLE EMAIL DRAFT:
Dear (insert Commissioner name)
We am writing to express concern with two model insurance regulations circulated for public comment on September 30, 2014. The regulations relate to the individual market and small group coverage.
Of great concern to us is section 14(B) of the individual market model and section 15(B) of the small group model both would permit health insurers to exclude from the annual limit “benefits provided out-of-network.” This is inconsistent with statutory language (see ACA section 1302(c)), and may make out-of-pocket protection more or less illusory in light of well-documented concerns with narrow networks. Moreover, the NAIC’s language is broad enough that it could – in theory – be interpreted by plans to excluded benefits covered through an appeal or exception process. This would be a step backward from current practice.
It is our understanding that NAIC is also working on a new network adequacy model law designed to protect consumers’ access to providers and services while still offering flexibility for health plans and regulators. This issue is so important that Commissioner Monica Lindeen of Montana (Chair-elect of the NAIC), testified before Congress in June 2014 that “the primary objective of network adequacy regulation . . . is to ensure that if an insurer requires enrollees to receive benefits from in-network providers, or provides financial incentives to do so, the network is capable of providing those benefits to enrollees when needed.” For rare disease patients in particular, this is crucial.
We urge the NAIC to continue to work with the many patient groups and other interested parties who have expressed concern about the treatment of cost sharing for out-of-network benefits in these Models. A number of substantive recommendations have been made, and we hope that the task force will take the time necessary to fully discuss and consider how this issue is addressed in the Models to ensure that sufficient protections are in place for consumers who must access out of network benefits. Rare disease patients in particular often must seek care out-of-network for a variety of reasons, often neither desired of voluntary.
Finally, we note that the NAIC network adequacy model is being amended currently, as well. All of these models should work hand in hand to ensure consumers have sufficient protections both in and out of network. To that end, before finalizing the Individual and Small Group Market Models, we urge the task force to work with the network adequacy task force to ensure adequate network protections are in place. Network adequacy and out-of-pocket protection are both critical in ensuring rare disease patients have appropriate access to necessary care.
For more background Information:
The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization created and governed by chief insurance regulators from all 50 states, D.C., and five U.S. territories. State regulators work through NAIC to establish standards and best practices, and to coordinate regulatory oversight (e.g., through the adoption of Model Laws and Regulations). Following enactment of the ACA, the NAIC undertook a number of work streams to build, enhance or clarify state-based regulation of health insurance.