For plan years beginning on or after January 1, 2014, non-grandfathered health plans may not discriminate against health care providers acting within the scope of their licenses. For example, this could prevent a plan from denying benefits solely because a doctor prescribed a drug for an off-label purpose or provided a service outside the doctor's typical specialty area (assuming both acts were within the scope of the doctor's license). The Agencies stated that this provision is self-implementing and they will not issue guidance in the near future.
Provider Non-Discrimination Hot Topics & FAQs
- Provider Non-Discrimination
For plan years beginning on and after January 1, 2014, Health Care Reform prohibits a non-grandfathered group health plan from discriminating against any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. Health Care Reform does not require that a group health plan accept every willing provider into its network or other arrangement, and it does not prohibit a plan from varying reimbursement rates based on quality or performance measures.
In the FAQs, the Agencies state that this section is “self-implementing”, and they do not expect to issue regulations in the near future. The Agencies indicated that until further guidance is issued, group health plans are required to implement this provision using a good faith, reasonable interpretation of the law. In making this good faith determination, a group health plan may use reasonable medical management techniques with respect to frequency, method, treatment or setting for an item or service, if the group health plan does not discriminate based on the provider’s license or certification and the provider is acting within its scope. For more information on provider non-discrimination, click here.
American Fidelity Assurance Company does not provide tax or legal advice.