ACA Legislation and Impact on PNPs

Dear Chapter Officers,

We want to bring to your attention an emerging issue in the implementation of the Affordable Care Act related to provider panels within the Health Insurance Marketplace (Exchange) that may have a negative effect on the ability of pediatric nurse practitioners (PNPs) to provide care to some of their current patients and other children in the communities that they serve.

Background: 

Under the Affordable Care Act, there are tiers of plans offered through federal/state/hybrid exchanges: Platinum, Gold, Silver, and Bronze plans. They vary by the percentage of costs a patient will pay for health care coverage they receive. The lower tier plans have less expensive monthly premiums but require a patient to pay for a greater percentage of the cost of care in the form of deductibles and co-payments (Bronze 40%, Silver 30%, Gold 20%, and Platinum 10%). As part of the effort to keep premiums down, insurers are creating smaller provider networks for these plans which may impede access to advanced practice nurses (APRNs). There is a concern that APRNs, including pediatric nurse practitioners, are not being adequately represented in these smaller networks, especially in light of the provider nondiscrimination clause of the Affordable Care Act* (see below) that went into effect in January of 2014.

Action Requested:

1)      NAPNAP members are encouraged to contact the insurers offering plans in the Health Insurance Marketplace in their states and ask to be credentialed as a provider. If the insurer denies this request, please ask for the reason for denial in writing and forward these responses to healthpolicy@napnap.org. Please be sure that the communication identifies both the state and the insurer. This type of documentation is necessary for NAPNAP to advocate on members' behalf in situations where to patient access to the care provided by PNPs is being restricted.

2)      Members are requested to begin a dialogue with their State Insurance Commissioner. The duties of the position vary from state to state, but their general role is a consumer protection advocate and insurance regulator. These officials need to be informed about the increasingly important role of PNPs and other APRNs providing needed access to health care in their states, and also informed of barriers to access to such care due to insurance industry practices that may be identified. Members should inquire if the Commissioners is aware of the provider non-discrimination provision of the Affordable Care Act*  and ask how it is being enforced within the program. If you are unfamiliar with your State Insurance Commission, use Google to search for his/her webpage and contact information. 

*Affordable Care Act SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

Section 2706 (now codified as 42 U.S.C. Sec. 300gg-5) goes into effect in 2014 and covers virtually all individual and group insurance market policies, although it is not clear whether it will apply to existing policies "grandfathered" in 2010 by the ACA.