New DOL Guidance Places Conditions on Employers Using Reference Pricing and Narrow Networks

Federal Health Care Reform

Late last week, the Department of Labor issued guidance that identifies the factors the Department will consider in evaluating whether non-grandfathered employer health plans using reference-based pricing designs have reasonable methods in place to ensure the plans provide adequate access to health care providers and disclosure to employees.  Pending issuance of future guidance, it would appear that most plans with reference-based pricing that treat providers accepting the reference amount as the only in-network providers should only apply reference-based pricing to those health care services where there is enough time for individuals to make an informed choice of providers.  Reference-based pricing will not be considered reasonable with respect to emergency services.  Specifically, employer plans should:

• Have procedures to ensure there are an adequate number of providers that accept the reference price, taking into account network adequacy approaches developed by States, reasonable geographic distance measures, and patient wait times;
• Have procedures to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards;
• Have an easily accessible exceptions process, allowing services rendered by providers that do not accept the reference price to be treated as in-network; and
• Disclose through the plan's Summary Plan Description, or similar document, information on the pricing structure, the list of services the pricing structure applies to, and the exceptions process.

DOL will continue to monitor the use of reference-based pricing and employers should be prepared to turn over descriptions of the procedures they have in place during an investigation by the Department’s Employee Benefits Security Administration, which has recently stepped up its ACA enforcement.