BIO joined with the American Pharmacists Association (APhA), Association of State and Territorial Health Officials (ASTHO), Immunization Action Coalition (IAC), Merck, and the National Association of County and City Health Officials (NACCHO) to submit comments to the Centers for Medicare and Medicaid Services (CMS) regarding the February 4, 2014 Draft Letter to Issuers in the Federally-facilitated Marketplaces.
BIO’s comments address the issue of network adequacy for immunization services provided under health plans offered in federally-facilitated marketplaces under the Affordable Care Act (ACA) and comments specifically on the following issues:
While we understand and support the continued role for states in the regulation of health insurance, there is a critical need for CMS to ensure Qualified Health Plan (QHP) compliance with the ACA’s “immunization coverage standard,” as this requirement is inextricably intertwined with the QHP-specific requirements related to network adequacy;
In reviewing the adequacy of QHP provider networks under the new “reasonable access” standard, in addition to those areas “which have historically raised network adequacy concerns,” such as primary care providers, CMS should ensure that QHPs include in their networks those provider types that furnish benefits promised under the ACA—including Advisory Committee on Immunization Practices (ACIP)-recommended immunizations;
CMS should refine the applicable Essential Community Provider (ECP) standards by requiring QHPs to include in their networks all types of complementary immunization providers (i.e., pharmacy, public health department clinic, school-based clinic, or other community site) in each county in the service area; and
CMS should stipulate that all ACIP-recommended immunizations, whether provided in- or out-of-network, are covered and exempt from cost-sharing requirements, either in the revised 2015 Letter to Issuers or in the regulations currently under development by the Agency.