The vast majority of provider networks available through qualified health plans (QHP) on the health insurance exchanges or marketplaces are “narrow” networks. These networks generally offer a limited set of providers with the goal of offering lower premiums and keeping costs down. As a result of their exclusion of many providers, including even large health systems, the networks have begun facing legal challenges from excluded providers, patients whose providers are excluded, and even state legislatures. Despite these many challenges, the greatest obstacle for QHPs to continue offering narrow networks appears to be coming from the Centers for Medicare & Medicaid Services (CMS) that has recently issued a new review standard for QHP networks. This standard offers CMS the opportunity to play an expanded role in the review and the approval of QHP networks.
Squire Sanders associate David E. Kopans recently wrote an article for American Health Lawyers Association’s Health Lawyers Weekly discussing that, while private and state efforts to challenge narrow networks appear unlikely to result in material changes, the newly proposed CMS review standard could potentially have a major impact on QHP narrow networks going forward.
The article was published in Health Lawyers Weekly (Mar. 14, 2014). Copyright 2014, American Health Lawyers Association, Washington, DC. Reprint permission granted.