Agencies Issue Guidance on Reference-Based Pricing for Nongrandfathered Health Plans

Nongrandfathered group health plans now have “specific factors” to determine whether their reference-based pricing provides adequate access to enrollees, according to new guidance.

To determine compliance, the three federal departments implementing the Affordable Care Act said in the guidance, issued Oct. 10, that they will evaluate whether plans:

• have standards to ensure that the network enables the plan to offer benefits for services from high-quality providers at reduced costs;
• have procedures to ensure that enrollees have reasonable access to providers;
• have procedures for ensuring that providers meet reasonable quality standards;
• have an easily accessible exceptions process; and
• and provide ...