ACA Accreditation Can Raise Administrative Issues

By Ferd H. and Cheryl C. Mitchell

Qualified-Health-Insurance-PlansUnder the Affordable Care Act (ACA), all of the Qualified Health Plans (QHPs) sold through the new Health Exchanges must be accredited. Two groups have been approved to conduct such accreditation activities, while an application from a third group is being processed.

According to the ACA statutes, the QHPs must offer 10 defined types of services: ambulatory care, emergency care, hospital care, maternity care, mental health services, prescription drugs, rehabilitative services, laboratory services, preventive care, and pediatric services.

But the statutes and regulations do not define the type of balance that is to be provided among these types of services, or how the quality of care is to be considered. This is where the accreditation groups are involved.

The accreditation procedures help define how insurance companies must structure their policies.  The requirements can limit innovation in insurance plan design and potentially limit access by narrowing the range of alternative care options.

When administrators encounter limitations on available health care services, accreditation procedures may be examined.

Accreditation information is generally available online (as noted in the above linked materials) and may be used to advocate for the availability of services.

If accreditation requirements are not being met, efforts may be required to “push” insurance companies and providers to revise their activities and procedures.

From another perspective, specific accreditation requirements may be found to be inadequate, in that provisions for client needs and preferences may not be included in available QHPs. This can happen when clients want to access care that is outside the range of approved services.

Public and nonprofit organizations may then address their concerns directly to the accreditation groups, and advocate for changes inState-Exchanges the procedures that are being applied. Arguments may be put forward for increased flexibility.

Widespread efforts of this nature might convince accreditation groups that provisions should be made to allow for more flexibility with respect to care coverage. Perhaps  “waiver options” could be added to accommodate preferences.

When advocates encounter problems with health care coverage, justification for the actions being taken by insurance companies and providers may often be based on a their statements that “this is an accreditation requirement”. This answer is intended to prevent further discussion.

It is important for advocates to realize that the accreditation process is accessible, and is so complicated that there may be room for debate over denials and restrictions for services.

As the Health Care System continues to grow more complex, and the ACA requirements continue to be felt, administrative agencies can best act on behalf of clients by understanding “how the system works” in order to obtain the best outcomes possible.

Organizations that are in the background, such as accrediting agencies, can often provide an alternative approach for problem solving.

This is installment #10 in the “Affordable Care Act and Public Administration” series.

Previous installments of this series have considered impact of the ACA on the field of public administration from a variety of perspectives. Refer to the archived postings for this blog to review all of these installments and obtain an overview of the combined commentary.

More on these and related ACA topics may be found in a recent book by the authors that describes implementation of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.

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