Network Adequacy and Essential Community Providers

Transcription

1 Network Adequacy and Essential Community Providers July 9, 2014 Laura Spicer, Maansi Raswant, & Brenna Tan Maryland Health Benefit Exchange (MHBE) Standing Advisory Committee

2 Agenda Introduction Federal Requirements Maryland Landscape Other State and Medicaid Examples Policy Options -2-

3 Introduction Network adequacy refers to a plan s ability to provide access to sufficient in-network providers Essential community providers (ECPs) serve low-income and medically underserved populations Federally qualified health centers, Ryan White providers, family planning providers, Indian health providers, specified hospitals, etc. -3-

4 Federal Network Adequacy and ECP Requirements -4-

5 Federal Requirements: The Affordable Care Act ACA 1311 Requires the Secretary of the U.S. Department of Health and Human Services (HHS) to establish criteria for certification of qualified health plans (QHPs), including requirements to: Ensure a sufficient choice of providers Provide information on the availability of both in-network and out-of-network providers Include ECPs within plan networks -5-

6 Federal Requirements: ACA Regulations 45 CFR Network Adequacy A QHP issuer must ensure that the provider network of each of its QHPs, as available to all enrollees: Includes ECPs (as explained in the next slide) Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay Is consistent with the network adequacy provisions of 2702(c) of the PHS Act, which allows network plans to limit the number of enrollees based on an enrollee s relation to the service area or the network s capacity A QHP issuer must also make its provider directory available to the Exchange for posting online and to potential enrollees upon request. The directory must indicate providers that are not accepting new patients. -6-

7 Federal Requirements: ACA Regulations continued 45 CFR ECPs QHP issuers must have a sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP's service area, in accordance with the Exchange's network adequacy standards. Where a QHP issuer provides a majority of covered professional services through physicians employed by the issuer, or through a single contracted medical group, the issuer must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities, to ensure reasonable and timely access for low-income, medically underserved individuals in the QHP's service area, in accordance with the Exchange's network adequacy standards. -7-

8 Federally Facilitated Exchange (FFE) Requirements Regulations lay out additional standards for issuers in the FFE For 2015, at least 30% of available ECPs in each plan s service area must participate in the provider network If an issuer s application does not satisfy the 30% ECP guideline, the issuer must include a satisfactory narrative justification as part of its application -8-

9 Maryland Landscape -9-

10 Maryland Landscape In 2012, the MHBE Board adopted interim procedures requiring QHP issuers in the state to follow federal regulations related to ECPs. These interim procedures covered year one of MHBE operations. On April 15, 2014, the MHBE Board approved 2015 plan certification standards, including the following related to ECPs: The MHBE should work with Hilltop to conduct necessary analyses of 2014 experience; seek input from the Standing Advisory Committee; and develop recommended metrics for ECP engagement adequacy standards to be adopted for plans offered in

11 Non-Exhaustive HHS List of ECPs in Maryland by County County Number of ECPs County Number of ECPs Allegany County 3 Howard County 4 Anne Arundel County 7 Kent County 2 Baltimore City 82 Montgomery County 16 Baltimore County 14 Prince George's County 15 Calvert County 1 Queen Anne's County 2 Caroline County 15 Somerset County 4 Carroll County 1 St Mary's County 3 Cecil County 3 Talbot County 11 Charles County 3 Washington County 5 Dorchester County 8 Wicomico County 9 Frederick County 3 Worcester County 4 Garrett County 4 Total 224 Harford County 5 Source: CMS, Non-Exhaustive HHS List of Essential Community Providers (2015 benefit year) -11-

12 Other State and Medicaid Examples -12-

13 Establishing State Standards States have considerable flexibility in interpreting the federal standard and enacting additional requirements States currently use quantitative or subjective approaches for establishing network adequacy standards -13-

14 Establishing State Standards continued Examples of quantitative standards: Provider-to-enrollee ratios Maximum travel time Maximum travel distance Maximum appointment wait times Minimum number of providers accepting new patients Minimum percentage of available providers within a service area Subjective standards are more flexible and are similar to the reasonable access standard in federal regulations Most states standards are directed toward HMOs only -14-

15 Comparison of States Provider Network Adequacy Standards State No Additional Standards Maximum Travel Time Provider-to- Enrollee Ratio Maximum Appointment Wait Time Hours of Operation Specialist Standards Specifies Provider Type to Be Included in Network AR CA CO CT DE DC IL IA MD MI MN NV NH NM NY OR VT WA WV -15- Source: Rosenbaum, S., Lopez, N., Mehta, D., Dorley, M., Burke, T., & Widge, A. (2013, December). How are state insurance marketplaces shaping health plan design?

16 Comparison of States Essential Community Provider Standards State No Additional Standards Specific Provider Types Identified Specific Geographical Access Measures Expanding ECP Definition Specific Participation Targets Identified AR CA CO CT DE DC IL IA MD MI MN NV NH NM NY OR VT WA WV -16- Source: Rosenbaum, S., Lopez, N., Mehta, D., Dorley, M., Burke, T., & Widge, A. (2013, December). How are state insurance marketplaces shaping health plan design?

17 Other State Network Standards Four states have additional ECP requirements California requires plans to have contracts with at least 15% of 340B providers in a plan service area Connecticut requires plans to include 75% of all ECPs, and plans are specifically directed to contract with community health centers -17-

18 Maryland Medicaid Network Standards An MCO must provide a complete network of adult and pediatric primary care, specialty care, ancillary service, vision, pharmacy, and home health An MCO must establish mechanisms to ensure that network providers comply with access requirements, monitor regularly to determine compliance, and take corrective action if there is failure to comply -18-

19 Maryland Medicaid Network Standards continued The enrollee-to-provider ratio for adults must be under 2,000:1, or 1,500:1 for children under the age of 21 An MCO must have a provider network that ensures enrollees have access to: primary care, pharmacy, OB/GYN, diagnostic laboratory, and -ray. An MCO should provide these services: In urban areas, within 10 miles of each enrollee's residence In rural areas, within 30 miles of each enrollee's residence In suburban areas, within 20 miles of each enrollee s residence -19-

20 Policy Options -20-

21 ECP Policy Options No additional standards beyond federal requirements Adopt FFE standards Adopt other requirements for contracting with a specific number or percentage of ECPs in a plan s service area Apply these requirements to all ECP types or a subset of ECP types -21-

22 Network Adequacy Policy Options No additional standards beyond federal requirements Adopt additional quantitative requirements Mileage Wait times Provider-to-enrollee ratios Adopt additional subjective requirements -22-

23 References CMS. (2014, March 14) letter to issuers in the federally-facilitated marketplaces. Retrieved from Corlette, S., Volk, J., Berenson, R., & Feder, J. (2014, May). Narrow provider networks in new health plans: Balancing affordability with access to quality care. Retrieved from McCarty, S., & Farris, M. (2013, August). ACA implications for state network adequacy standards. Retrieved from CMS. (2015 benefit year). Non-exhaustive HHS list of essential community providers. Retrieved from Rosenbaum, S., Lopez, N., Mehta, D., Dorley, M., Burke, T., & Widge, A. (2013, December). How are state insurance marketplaces shaping health plan design? Retrieved from

24 About The Hilltop Institute The Hilltop Institute at UMBC is a non-partisan health research organization with an expertise in Medicaid and in improving publicly financed health care systems dedicated to advancing the health and wellbeing of vulnerable populations. Hilltop conducts research, analysis, and evaluations on behalf of government agencies, foundations, and nonprofit organizations at the national, state, and local levels. Hilltop is committed to addressing complex issues through informed, objective, and innovative research and analysis

25 Contact Information Laura Spicer Senior Policy Analyst The Hilltop Institute University of Maryland, Baltimore County (UMBC)