Any health insurance company or health insuring corporation (“HIC”) doing business in the State of Ohio must report significant changes to their provider networks to the Ohio Department of Insurance, according to the Insurance Bulletin 2009-01 issued by the Ohio Department of Insurance on January 20, 2009.
More specifically, the Bulletin requires that at least fifteen (15) days prior to contacting policyholders about the expiration of a contract with a hospital or major physician group, health insurers and HICs must provide to the Department’s Office of Risk Assessment a written submission including the following: (1) the process and procedures by which subscribers or insureds and any affected participating providers will be notified of any impending contract termination and resulting changes in the health plan provider network, including providing to the Department copies of written or electronic communications, such as letters to be sent to subscribers or insureds and any affected participating providers notifying them of the impending change in network; (2) the options and rights, including all continuity of care provisions, to be provided to subscribers or insureds; and (3) all company contacts for information and assistance, including telephone numbers and e-mail addresses, to be provided to subscribers or insureds and any affected participating providers.
“Major physician group” means a physician group that provides services to a large population of the health insurer's or HIC’s membership in a specific geographic area and/or that receives a substantial portion of its reimbursement from the health insurer or HIC.
Health insurers and HICs may comply with this Bulletin by annually submitting the documentation described above and subsequently providing the required 15 day notice, including written confirmation that the documentation previously filed will be sent to subscribers or insureds and any affected participating providers.
Before the Bulletin, insurers and HICs were not required to notify the Department of any change to its provider network and often shift the burden of notifying policyholders of termination of provider agreements onto participating providers. Providers find it impossible to comply with such requirements because they do not necessarily know who the policyholders are. Also, complying with such requirement means higher administrative costs to providers. Providers often do not have the staff or software to handle such tasks.
The Bulletin has changed such practices. It not only requires health insurers and HICs to notify the Department of termination of a hospital or major physician group, but expressly requires that the insurers and HICs notify subscribers and insureds and participating providers impacted by the change of provider networks. Also, the Bulletin is not limited to just termination, but also expiration of provider agreements.
However, the Bulletin fell short of some necessary clarity. Despite the definition of “major physician group,” it is not clear whether any particular physician group falls within the definition as a health insurer and HIC would not know for sure whether any particular group has received a substantial portion of its reimbursement from the health insurer or HIC.
Further, the Bulletin excludes Medicaid managed care plans (in addition to supplemental or specialty health care services only providers), but not Medicare managed care plans. So, it is unclear whether any insurer or HIC that offers Medicare managed care plans will be required to comply with the Bulletin.