by Emily Michels, Health Policy Fellow

The process of drafting a law is a long and arduous one, especially when the legislation in question is trying to tackle large-scale issues such as ensuring that appropriate types and amounts of health care services are available for an entire state. But behold! The concept of a model law – a document that states can use as a “jumping off point” for their own legislation, choosing to adopt or exclude certain aspects depending on how it might fit with their existing state laws. The National Association of Insurance Commissioners (NAIC) is working on Model Law #74, which focuses on ensuring that carriers provide consumers with sufficient access to all types of providers, and covers everything from carrier requirements for network access plans to the accuracy of provider directories and balance billing.

After many months of drafting and editing by a workgroup of the NAIC and input from stakeholders representing providers, carriers, and consumers, among others, the model law draft is now moving toward final approval by the full NAIC. Once completed, this model law will give Colorado some new language to work from in considering our current network adequacy standards.

Why might we need a model law on network adequacy? Why are these issues important enough to warrant months of weekly calls and numerous drafts and comments from dozens of organizations? It’s simple.  Having a sufficient network is the foundation of consumers having access to the health care services they need. A network, or the group of providers and resources available to a consumer through his or her insurance plan, must be “adequate” enough to meet the needs of the policyholders. The criteria for this adequacy, however, are vague at best, and are often left up to individual carriers instead of a uniform authority.

That’s where the model law steps in.

The last version of this model law was finalized in October 1996 and with all of the recent changes to the health care sphere since then, an update to the language was due. This updated draft includes a more robust set of consumer protections and language that aligns with the principles put forth in the Affordable Care Act. And while the 2015 version makes some elements optional for states by including drafting notes that leave the decision to include the language up to each state, there is an overall sentiment that the model law is a vast improvement from its pre-ACA relative.

As consumer advocates, we support the following additions to the model law draft:

  • Network sufficiency determinations by division of insurance: The model law shifts the responsibility of deeming a network adequate or not from the individual carriers to state regulators.
  • A stronger process for consumers to use non-participating providers if necessary: Language is included to provide a better system for consumers to find and use out-of-network providers without penalization if there is no appropriately-trained provider in a consumer’s network.
  • Continuity of care provisions: Model law language touches upon ways to avoid gaps in coverage and care for consumers.
  • Provider directory requirements: The NAIC law includes requirements for what information must be provided in a directory and standards for accuracy of these directories.
  • Balance billing language for emergency services and in-network facilities: The law discusses protections for consumers who use out-of-network providers in cases of emergency or good faith efforts to attend an in-network treatment facility.

Of course, as consumer advocates, we continue to strive for the perfect piece of legislation that will protect and represent the consumer voice. The NAIC consumer representatives, as a joint effort with provider groups, wrote a letter identifying a few elements that they would still like to see included in the model law, as follows:

  • Requirement for clear, quantitative measures to assess network adequacy
  • Tighter regulations of tiered networks to ensure that consumers with expensive medical needs are not discriminated against. The specific request here is that network adequacy standards should apply to the lowest cost-sharing tier and that all essential health benefits (EHBs) are available on the lowest tiers.
  • Requirement that provider networks be approved by state regulators before plans can be sold to consumers

The consumer representatives and the organizations they represent are committed to creating a model law that allows consumers to have and use their health insurance to its fullest extent. The NAIC workgroup have approved Model Law #74 thus far, so it now moves on to be discussed and voted on at the National Conference next week.

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