HealthCare.gov's 'name your own price' plans start to take shape

To see whether doctors in a patient's area will really provide care for the prices the plan is offering to pay, a non-network plan will have to conduct "continuous outreach to available providers" to see what they think about the prices offered, according to the new 2027 exchange rules letter.

A non-network plan will also have to post a detailed list of the prices it's willing to pay doctors "in an easily accessible and understandable format where the public, including plan enrollees, potential enrollees, and providers... can access information about all available plan benefit amounts," officials say.

What it means: If more non-network plans come to life and work the way CMS officials expect, the plans' benefit amount lists could suddenly become a relatively short, easy-to-use list of prices that commercial health plans in a community really pay for care.

Instead of negotiating prices based on a percentage of what the traditional Medicare program pays for care, a health insurer or administrator of a self-insured employer health plan could negotiate prices based at least partly on what the nearby non-network plans on HealthCare.gov pay.

Because most enrollees in the commercial health plans sold on HealthCare.gov are under age 65, rather than age 65 or older, the non-network plan price lists might be a better pricing benchmark for typical employer plans than traditional Medicare is.

HealthCare.gov: The Affordable Care Act of 2010 set up a network of web-based health insurance stores, or public exchange programs, to help shop for major medical coverage and use federal premium tax credit subsidies to pay for the coverage.

Fourteen states and the District of Columbia run their own ACA exchange programs.

HealthCare.gov provides exchange services in 36 states.

The Center for Consumer Information and Insurance Oversight is the division of the Centers for Medicare & Medicaid Services that runs HealthCare.gov.

Non-network plans: Fifty years ago, health plans with provider networks were unusual.

Today, most major medical health plans encourage patients to see in-network providers. Patients who see in-network providers may have to pay deductibles, coinsurance amounts and co-payments, but, once they have seen in-network providers, followed other plan rules, and paid the "cost-sharing" amounts described in their plan documents, they may not have to worry about getting any additional bills.

The kinds of HealthCare.gov non-network plans envisioned by CMS officials are plans that use a "reference-based pricing" system, or "name your own price" system, rather than provider network agreements to manage plan costs.

Priceline lets travelers use a reference-based pricing system to book hotel rooms: A traveler enters a price for a hotel room, then sees if any suitable hotels are willing to match that price.

A health plan with a name-your-own-price strategy posts lists of what it will pay for various medical products and services.

A patient in the non-network plan can go to doctors who will accept the plan's payment rates as payment in full. The patient may also be able to go to more expensive doctors and pay the difference between what the doctors charge and what the plan will pay.

CMS wants the name-your-own price plans sold on HealthCare.gov to offer payment rates that are high enough that about half of the doctors in a community will accept those payment rates as payment in full.

The backdrop: Name-your-own-price plans have been quietly gaining market share.

Lockton recently found that about 7% of the self-insured employer plans that it surveyed are using reference-based-pricing strategies.

Researchers at a Rice University research center looked at variations in plan costs at Texas university health plans and found that the cheapest options were reference-based pricing plans.

Related: Some employers pay 3x more for the same health coverage

But some providers and patient advocates have wondered how easily patients with the plans can find care.

The CMS perspective: The new CMS letter to HealthCare.gov plan issuers shows that CMS officials are also thinking about how easily patients will be able to find doctors who like a non-network plan's payment rates.

CMS will require the non-network plan issuers to address many provider-supply issues in their applications for participation on HealthCare.gov

In addition to describing a strategy for assessing how the providers in a community see the plan's reference prices, a non-network plan issuer will have to show how many provides are likely to accept the references prices offered, how the plan will explain the prices offered, and what the plan will do if an enrollee cannot find a provider willing to accept the reference prices as payment in full.

The plan will also have to provide a customer service team or online provider directory that can help enrollees find doctors who have agreed to accept the plan's prices as payment in full.