Reliable Provider Directories - Study
Reliable Provider Directories – Study

See our page on Balance Billing for information at AB 72 to help resolve the issue of going to a hospital or doctors office that is on the list, but still getting out of network bills.

One reason for the Narrow Network is that DOCTORS, Hospitals & other providers do NOT get reimbursed if a policy gets cancelled, because the insured did not pay their portion of the subsidized premium in the 2 or 3 month of the grace period.  45 CFR 155.430 (b) (2) (ii) (A) & (B) and 156.270 (d) – Federal Regulation 41866

(d) Grace period for recipients of advance payments of the premium tax credit. A QHP issuer must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month’s premium during the benefit year. During the grace period, the QHP issuer must:

(1) Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period;

(2) Notify HHS of such non-payment; and,

(3) Notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period.

(e) Advance payments of the premium tax credit. For the 3-month grace period described in paragraph (d) of this section, a QHP issuer must:

(1) Continue to collect advance payments of the premium tax credit on behalf of the enrollee from the Department of the Treasury.

(2) Return advance payments of the premium tax credit paid on the behalf of such enrollee for the second and third months of the grace period if the enrollee exhausts the grace period as described in paragraph (g) of this section. 156.270

3.04 Offerings Outside of Exchange.

(a) Contractor [Insurance Company] acknowledges and agrees that QHPs [Qualified Health Plan] and substantially similar plans offered by Contractor outside the Exchange must be offered at the same rate whether offered inside the Exchange or whether the plan is offered outside the Exchange directly from the issuer or through an agent as required under applicable laws, rules and regulations, including those required under 45 C.F.R. § 156.255(b), 42 U.S.C. § 18021, 42 U.S.C. § 18032. In accordance with Government Code Section 100503(f), Insurance Code Section 10112.3(c), and Health and Safety Code Section 1366.6(c), and other applicable State and Federal laws, regulations or guidance in the event that Contractor sells products outside the Exchange, Contractor shall fairly and affirmatively offer, market and sell all products made available to individuals [Free Quotes] and small employers [Free Quotes] in the Exchange to individuals and small businesses purchasing coverage outside the Exchange.

§156.230   Network adequacy standards.

The law appears to require that plans are exactly the same in and out of the Exchange – Covered CA

Section 1301 PPACA Qualified Health Plan Defined 42 U.S. Code § 18021   Covered CA & Insurance Company Contract §3.04

(B) provides the essential health benefits package described in section 1302(a);

(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange [Covered CA] or whether the plan is offered directly from the issuer or through an agent; and

§156.235 Essential community providers.

Link to an amendment published at 80 FR 10873, Feb. 27, 2015.

(a) General requirement.

(1) A QHP issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.

(2) A QHP issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph (b) of this section.

(3) Nothing in this requirement shall be construed to require any QHP to provide coverage for any specific medical procedure provided by the essential community provider.

(b) Alternate standard. A QHP issuer described in paragraph (a)(2) of this section must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.

(c) Definition. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, including providers that meet the criteria of paragraph (c)(1) or (2) of this section, and providers that met the criteria under paragraph (c)(1) or (2) of this section on the publication date of this regulation unless the provider lost its status under paragraph (c)(1) or (2) of this section thereafter as a result of violating Federal law:

(1) Health care providers defined in section 340B(a)(4) of the PHS Act; and

(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Act as set forth by section 221 of Public Law 111-8.

(d) Payment rates. Nothing in paragraph (a) of this section shall be construed to require a QHP issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.

(e) Payment of federally-qualified health centers. If an item or service covered by a QHP is provided by a federally-qualified health center (as defined in section 1905(l)(2)(B) of the Act) to an enrollee of a QHP, the QHP issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1902(bb) of the Act for such item or service. Nothing in this paragraph (e) would preclude a QHP issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would have been paid to the center under section 1902(bb) of the Act, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer indicated in paragraph (d) of this section.

New rules for Federal Exchanges about “Narrow” networks.

Plans generally would have to contract with at least 30% of essential community providers in their market, including community health centers, HIV/AIDS clinics, and children’s hospitals.

Rules PDF
modernhealthcare.com

Article
modernhealthcare.com/

 

From another well informed agent, who is also setting up training for TX navigators

the statute does not use the term “mirror”, but how would a plan off the exchange have the same premium if it did not provide the same benefit [including networks] structure?

Section 1301 PPACA Qualified Health Plan Defined Page 44 steveshorr.com

(B) provides the essential health benefits package described in section 1302(a);

(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange [Covered CA] or whether the plan is offered directly from the issuer or through an agent; an

Parent Page – Child & Sibling Pages

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