CMS advocates for health plan reform
by Susan Koontz, JD, CMS General Counsel
Surveys of CMS members demonstrate time and again deep dissatisfaction with the current multi-payer system. While member concerns span a variety of administrative and care-specific interferences, most CMS members are simply asking for reasonable incremental reforms that will result in more time for patients and less time on the hoops and hassles now ingrained in the system.
In response, CMS is seeking passage of a series of managed care reforms in the 2017 General Assembly. These reforms have inspired a healthy and long-overdue debate over the relationship between physicians and payers. We are deeply grateful to members of the General Assembly who have been willing to step up and promote fairness and greater transparency in the system, as well as the many CMS members who have completed our surveys, testified at hearings and taken the time to contact their elected officials.
SB17-088 - Participating Provider Network Selection Criteria
Sponsors: C. Holbert |
A. Williams / K. Van Winkle | E. Hooton
This bill requires a health insurer to develop, use and disclose to participating health care providers the standards the carrier uses for:
- Selecting participating providers for its network of providers;
- Tiering providers within the network; and
- Placing participating providers in a narrow or tiered provider network.
A carrier must disclose its standards to the commissioner of insurance for review and must make the standards available to providers and consumers. At least 60 days before implementing a decision to terminate a provider’s participation in one or more provider networks, a carrier must notify the affected provider in writing and inform the provider of the right to request that the carrier reconsider its decision. The bill requires the carrier to develop procedures for providers to request reconsideration and sets forth minimum requirements for, components of and deadlines for the procedures.
Upon request, and not more than quarterly, a carrier must provide to providers participating in at least one of its networks a complete list of all network plans and products it offers to consumers, indicating the participating provider’s status within each network plan or product.
This bill passed the Senate and is headed to the House.
SB17-133 - Insurance Commissioner Investigation
of Provider Complaints
Sponsors: J. Tate / D. Young
Currently, the commissioner of insurance may investigate complaints by health care providers regarding the improper handling or denial of benefits by a health insurance company. The bill requires the commissioner to investigate provider complaints and notify the provider of the results of the investigation. The commissioner is directed to include information on provider complaints in an existing annual report to the General Assembly. The commissioner must determine if there is a pattern of misconduct by a health insurance company and, if there is a pattern, must impose an appropriate remedy or penalty as an unfair or deceptive practice.
This bill was assigned to the Senate Business, Labor and Technology Committee on Jan. 31. Shortly after this bill was introduced, it was noted on the record that a pilot project is to be established by the Division of Insurance. If the details of the pilot can be worked out to the satisfaction of physicians, the bill will be voluntarily postponed indefinitely.
HB17-1094 - Telehealth Coverage Under Health Benefit Plans
Sponsors: D. Valdez | P. Buck / K. Donovan | L. Crowder
Under current law, health benefit plans are required to cover health care services delivered to a covered person by a provider via telehealth in the same manner that the plan covers health care services delivered by a provider in person. This bill clarifies that:
- A health plan cannot restrict or deny coverage of telehealth services based on the communication technology or application used to deliver the telehealth services;
- The availability of telehealth services does not change a carrier’s obligation to contract with providers available in the community to provide in-person services;
- A covered person may receive telehealth services from a private residence, but the carrier is not required to pay or reimburse for any transmission costs or originating site fees the covered person incurs;
- A carrier is to apply the applicable copayment, coinsurance, or deductible amount to health care services a covered person receives through telehealth, which amount cannot exceed the amount applicable to those health care services when delivered through in-person care; and
- Telehealth includes health care services provided through HIPAA-compliant audio-visual communication or the use of a HIPAA-compliant application via a cellular telephone but does not include voice-only telephone communication or text messaging.
The bill was signed by the governor on March 16.
HB17-1173 - Health Care Providers and Carriers Contracts
Sponsors: C. Hansen / T. Neville
Current law requires a contract between a health insurance carrier and a health care provider to include a provision that prohibits a carrier from taking an adverse action against the provider due to a provider’s disagreement with a carrier’s decision on the provision of health care services. The carrier cannot terminate the health care provider’s contract for disagreeing or for assisting his or her patient in seeking a reconsideration.
The bill requires the contract to also contain provisions that prohibit a carrier from: taking adverse actions for communicating with public officials on health care issues; filing complaints or reporting to public officials about conduct by a carrier that might negatively affect patient care; providing information concerning a violation of this provision; reporting alleged carrier violations to the appropriate authorities; or participating in an investigation of an alleged violation.
The bill passed the House and is scheduled for hearing on March 20 before the Senate Business, Labor and Technology Committee.
SB17-198 - Public Participate Review Acquire Control Insurer
Sponsors: K. Priola / A. Garnett
Current law requires an opportunity for public notice and a hearing for proposed transactions that would result in the acquisition of control of a domestic insurer, which is one that is incorporated or formed pursuant to Colorado law. Section 1 of the bill expands the public notice for acquisition of a domestic insurer that offers health plans by requiring the commissioner of insurance to make the entire pre-acquisition notification available for public inspection promptly after filing. Section 2 requires the commissioner to subject proposed transactions that would result in the acquisition of control of a foreign insurer that offers health plans to public participation requirements that are analogous to those that would be required for domestic insurers that offer health plans.
The bill was heard on February 28 before the Senate, Business, Labor and Technology Committee and testimony was taken. The Committee will vote on the bill on March 21.
SB17-206 - Out of Network and Surprise Bills
Sponsors: B. Gardner / J. Singer
This bill provides a framework to resolve the long-standing out-of-network balance billing problem and requires that carriers, facilities and providers all notify patients of their legal protection for OON bills under current Colorado law. A hearing is scheduled on March 21 before the Senate Business, Labor and Technology Committee.
SB17-203 - Prohibit Carrier From Requiring
Sponsors: N. Todd / C. Kennedy | P. Covarrubias
The bill prohibits a carrier from requiring a covered person to undergo step therapy:
- When being treated for a terminal condition; or
- If the covered person has tried a step-therapy-required drug under a health benefit plan and the drug was discontinued by the manufacturer.
A carrier that requires step therapy must have an override process for health care providers. “Step therapy” is defined as a protocol that requires a covered person to use a prescription drug or sequence of prescription drugs, other than the drug that the covered person’s health care provider recommends for the covered person’s treatment, before the carrier provides coverage for the recommended drug.
This bill passed out of the Senate Business, Labor and Technology Committee on March 15.
SB17-084 - Coverage for Drugs in a Health Coverage Plan
Sponsors: C. Jahn / D. Esgar | J. Singer
The bill prohibits a health insurance carrier from excluding or limiting a drug for an enrollee in a health coverage plan if the drug was covered at the time the enrollee enrolled in the plan. A carrier may not raise the costs to the enrollee for the drug during the enrollee’s plan year.
This bill was postponed indefinitely on Feb. 9 in the Senate Committee on Health and Human Services.
We encourage physicians to stay involved with CMS during the session by testifying or calling your legislators to urge their support. Watch for special legislative alerts or contact Adrienne at email@example.com or 720-858-6322 for more information.
Posted in: Colorado Medicine | Legislative Updates | Practice Evolution | Payment Reform | Interacting With Payers | Initiatives | Advocacy