Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

EDPMA and ACEP Comment on Fair Coverage


The Emergency Department Practice Management Association (EDPMA), in cooperation with the American College of Emergency Physicians (ACEP), submitted to the Centers for Medicare and Medicaid Services (CMS) a number of comments about the Notice of Benefit and Payment Parameters for 2018, “urging it to require ACA health plans to offer fair coverage including adequate reimbursement for emergency care.”

In late August, CMS issued the proposed Notice of Benefit and Payment Parameters for 2018, which calls for strengthening the Health Insurance Marketplace. Specifically, the proposal attempts to improve risk adjustment in the Marketplace as well as improve the Marketplace consumer experience and strengthen the individual and small group markets as a whole.

The EDPMA/ACEP letter calls on CMS to change a number of items in the proposal which address two primary concerns: First, the organizations are concerned that the proposal in its current form “could discourage access to a critically important essential health benefit – emergency care.” Second, they believe that “essential benefits” of the Affordable Care Act (ACA) should not be covered and fairly reimbursed by Qualified Health Plans (QHPs).

Specifically, the letter urges CMS to amend the rule as follows:

  • “Express the proposed maximum patient contribution for an Emergency Room Visit under Gold, Silver, and Bronze Policies as a limited dollar amount (and not as a percentage of the cost of care),
  • Exempt emergency services from the deductible and allow patients to count out-of-network payments for emergency care toward annual limits on in-network cost sharing,
  • Clarify that, under the Greatest of Three rule, “Usual, Customary, and Reasonable” rates must be based on an objective transparent historical charge database,
  • Require an adequate network of emergency physicians, and
  • Discourage adoption of Section 7 of the NAIC Model on Network Adequacy.”

An EDPMA-ACEP Joint Task Force was commissioned by the two groups to work on the issues of fair coverage and fair reimbursement for out-of-network emergency care. For more information on their efforts, read a copy of their comment letter which was sent to CMS Acting Administrator Andy Slavitt or review a recent ACEP Now article about the Task Force.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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