Changes from 2015 to 2016... Rules, Premiums, Plans, Exchanges, Etc.
- Thread starter AllenChicago
- Start date
I wonder if those regs will help the issue of "significant misrepresentation" caused by multiple listings?
Some companies are listing the same doctor 2-10 times, once for each location they are associated with. They (DOI/DFS) base network adequacy off of the totals, but no one checks how many times they list the same doc.
When one company says there's 350 cardiologists within 10 miles, and another says they have 200, we all know which one consumers want. When the reality is that the company with 350 only has 150 with most listed many times, consumers aren't getting what they expect.
Half the time, it's the exact same name and phone number. I've seen doctors listed 7x because their office is made of 6 suites put together and they have admitting privilege at a hospital
Some companies are listing the same doctor 2-10 times, once for each location they are associated with. They (DOI/DFS) base network adequacy off of the totals, but no one checks how many times they list the same doc.
When one company says there's 350 cardiologists within 10 miles, and another says they have 200, we all know which one consumers want. When the reality is that the company with 350 only has 150 with most listed many times, consumers aren't getting what they expect.
Half the time, it's the exact same name and phone number. I've seen doctors listed 7x because their office is made of 6 suites put together and they have admitting privilege at a hospital
The fine is up to $25K for an MAPD plan making an error, up to $100 for ACA
The much larger issue for consumers is that when they ask a doctor's office if they take UHC, the office can say 'Yes' even though they may only take a commercial, group plan and have nothing to do with an ACA or MAPD plan-consumers don't know to ask about a specific network (they usually have no clue) and doctor's offices really don't care about whether they give the right answer or not as long as they get paid.
Maybe for MAPD, but $100 for ACA isn't even going to move the needle at all...
True, and it works the other way as well. I had a lady that called to check her Doctor's office for Uhc, and she called me back frantically saying that they told her that they didn't accept it, and neither did anyone else, that coverage was not available in this area...they assumed she was on an MA plan, which we don't have here, but they do take the Compass plan as I have several that use that same office. The lady is a pita anyway, but I put my two cents in, I mean my 2%.
Anyone have the official guidance? How they define the fine is very important.
I can't find it the official rule, but news reports I see say "per beneficiary", "per violation", and some say "per day". I presume "beneficiary" means "primary or dependent enrolled on a plan that uses the network in question", as that is how they define it for other reports (like the Medicaid Spending Per Beneficiary report).
200k enrolled, 100 errors out of 40,000 providers in your system, $100 fine per beneficiary/violation comes out to two billion dollars a day. Might be $2B per year if the "per day" claim is wrong. Might be only $20M if it's not per violation, and it might be significantly lower if it's only "per complaint" or "per contract".
No matter what, this isn't going to be a $100/day slap on the wrist until their directory is accurate. It's going to be a whole lot more.
If you're like BlueCross where 25%+ of your directory is inaccurate, and you have millions enrolled, a week worth of fines will shut you down...
EDIT: Full text of letter to insurers: https://www.cms.gov/CCIIO/Resources...ownloads/2016_Letter_to_Issuers_2_20_2015.pdf
Appears they will be amending 45 C.F.R. 156.805(a) to include network inaccuracy.
"(c) Maximum penalty. The maximum amount of penalty imposed for each violation is $100 for each day for each QHP issuer for each individual adversely affected by the QHP issuer's non-compliance;" implies it is per-individual on a plan with inaccurate network data.
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- Thread starter
- #198
- 8,448
12.30.2015
This administration's ignorance of how the real world operates never abates. Today, Sylvia Burwell says that 3 out of 5 existing insureds picked a different plan for 2016, because they're ENTHUSIASTIC about Obamacare. (And she was sober!)
Ref: HHS: 3 in 5 Obamacare customers shopped around for 2016 plan Washington politics
Everyone else in America realizes that the real reason for 3 out of 5 choosing a different plan for 2016, is because Obamacare forced health insurers to make policy changes that made existing 2015 plans too expensive, too impractical, or simply impossible to keep.
This administration's ignorance of how the real world operates never abates. Today, Sylvia Burwell says that 3 out of 5 existing insureds picked a different plan for 2016, because they're ENTHUSIASTIC about Obamacare. (And she was sober!)
Ref: HHS: 3 in 5 Obamacare customers shopped around for 2016 plan Washington politics
Everyone else in America realizes that the real reason for 3 out of 5 choosing a different plan for 2016, is because Obamacare forced health insurers to make policy changes that made existing 2015 plans too expensive, too impractical, or simply impossible to keep.
HealthRisk
Expert
- 43
Or they could have, maybe, adjusted the AV calculator in a way that made a large number of existing plans no longer metallic for the new year.
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Interesting that they say the fine will be assessed per day when the finalized rule on a provider directory on requires monthly updates.
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