2016: Year in Preview

Slimming too fast: New rules coming for narrowing networks


Jan Greene

The trend of smaller and more specialized health plan design is likely to continue in 2016 as insurers and employers look for ways to build networks that control costs without damaging quality.

Exchange plans for 2016 already reflect this. An analysis by Avalere found a 31% drop in the percentage of exchange plans offering PPO networks, while the use of HMOs and exclusive provider organizations (EPOs) has increased. PPOs are the health plan design that tends to have the broadest provider networks.

Type of networks offered in exchange plans

Source: Avalere

While those figures apply only to health plans in the federal and state ACA exchanges, insurers around the country are cutting back on PPO plans outside the exchanges as well. Blue Cross Blue Shield of Texas said it would discontinue all PPO plans for individuals and families next year.

There are also indications that insurers are focused on building sleeker network designs. For instance, Aetna recently unveiled Leap, a simplified accountable care type of plan with limited networks. Other big insurers are creating low-cost plans focused on just one provider network, responding to consolidation among hospitals and physician groups.

Regulators are alert to the changes, though, and some worry that the network design pendulum could swing too far, leaving patients without access to providers they need. The National Association of Insurance Commissioners (NAIC) is putting together a model law to ensure networks are adequate; it should be available to state legislatures in 2016. One of the key provisions of the model law requires health plans to cover a noncontracted provider at the in-network rate if the network doesn’t include the providers needed for a covered benefit.

Because it’s hard for consumers to choose a network without knowing what providers are in it, rules are tightening up on health plans’ obligations to maintain accurate provider lists. CMS recently told insurers on the federal marketplace and that offer Medicare Advantage plans that they must publish up-to-date, accurate and complete provider directories and update them each month. The federal government is also adding a feature to HealthCare.gov that allows health plan shoppers to search for plans by preferred provider or health care facility.

The NAIC model law also addresses provider directories, and would require monthly updates along with regular audits by the insurer.