THE PATH TOWARD NETWORK ADEQUACY

Transcription

1 Navigating the Nature of Rural Health Care THE PATH TOWARD NETWORK ADEQUACY 1 If you find a path with no obstacles, it probably doesn t lead anywhere. Frank A. Clark Do not go where the path may lead. Go instead where there is no path and leave a trail. Ralph Waldo Emerson 2 1

2 3 Network squeeze: Controversies continue over narrow health plans By Bob Herman March 28, 2015 (This article has been updated with a correction.) Los Angeles colorectal surgeon Dr. Allen Kamrava regularly faces financial challenges related to narrow-network health plans. He recently performed a gastrointestinal procedure on a patient at a local hospital. Both he and the hospital were in-network providers for the patient's plan. But unbeknownst to him and the patient, the anesthesiologists and pathologists involved in the procedure were not. So the patient ended up on the hook for $3,000 for those out-of-network provider services. Had the patient gone to a nearby out-of-network outpatient surgery center and paid for the entire procedure out of pocket, the total bill would have been less than $1,

3 2014 What Changed? 1. Anthem (CompCare) was in 72 counties, now Dean expanded to Vernon, Kewaunee 3. GHC SC expanded to Lafayette, Rock, Green; previously not a large individual market presence 4. Molina new to commercial market; previously Medicaid only 5. United, Humana chose not to participate in the Exchange 6. Common Ground new to Wisconsin; Coop plan established under ACA 3

4 County Insurers offering QHPs in the Insurance Exchange for 2015 Brown Anthem BCBS, Arise, Common Ground, Dean, Molina, United* Burnett Medica*, Security Columbia Anthem BCBS*, Arise*, Dean, GHC-SC, United* Crawford Dean, Gundersen, Health Tradition, Unity* Dane Dean, GHC-SC, Physician s Plus, Unity Grant Dean, Gundersen, Health Tradition, Unity* Jefferson Anthem BCBS, Dean, GHC-SC, MercyCare*, Molina, United*, Unity, -Arise LaCrosse Anthem BCBS*, Gundersen, Health Tradition, United* Marinette Anthem, Arise, Common Ground, Dean, Molina, United* Milwaukee Ambetter from MHS*, Anthem BCBS, Arise, Common Ground, Molina, United* Racine Ambetter from MHS*, Anthem BCBS, Arise, Common Ground, Molina, United* Rusk Health Tradition, Security, United* Wood Anthem BCBS, Arise, Common Ground, Dean, Molina, United* * = new to exchange for that county for 2015 benefit year Note Anthem new name in 2014 was Compcare. What is Network Adequacy? Regulators view NA from a consumer perspective Does the consumer have access to providers in order to receive services that are covered under their health care plan s benefits? ACA/Exchange: Insurer must maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to assure that all services will be accessible without unreasonable delay. 8 4

5 Health Insurance Market in WI Large Employer ,600,000 Small Employer ,000 Medicare ,800 Medicaid May ,200,000 BadgerCare 812,000 Elderly, Blind, Disabled 218,000 All Other 170,000 WI ETF ,000 Individual Market ,000 Exchange Enrollment As of 06/01/15 185,000 9 Who Regulates the Markets? Large Employer Self Insured Large Employer Large Group Small Employer Group Medicare Advantage Medicaid Managed Care WI State Employees (ETF) Individual Market Non Exchange Exchange Federal ERISA (DOL) State OCI State OCI Federal HHS/CMS State DHS State OCI State OCI Fed HHS/State OCI 10 5

6 Insurer must maintain a network that is sufficient in number and types of providers to assure that all services will be accessible without unreasonable delay. - Provider to covered person ratios - primary care and specialty - Geographic accessibility (travel times/distance) - Waiting times for visits with providers - Hours of operation - For Exchange essential community providers 11 PCP to Covered Person Ratios WI Medicaid 1:100 Members Medicare Advantage 1.67 per 1,000 for large metro areas; 1.42 per 1,000 for rural areas ACA/HHS Exchange No Ratio specified Current WI OCI No Ratio specified 12 6

7 Geographic/Distance Requirements WI Medicaid PCPs: within 20 miles; 10 miles for Mke/Ken/Racine Hospitals: 20 miles for Regns 5&6, Dane/Brown cnties; all other, 35 miles Medicare Advantage At least 90% of beneficiaries in the county have access to at least one provider for a given specialty within the time and distance requirements developed by HHS. Minimum provider ratios e.g inpatient hospital beds per 1,000 beneficiaries in a county. ACA/HHS Exchange Essential community providers insurer must include certain providers within each county within the service area Current WI OCI Geographic availability shall reflect the usual medical travel times within the community 13 Wait Times for Services WI Medicaid Less than 30 days for PCP; Less than 90 days for dental; Less than 30 days for follup mental health Medicare Advantage No provision ACA/HHS Exchange No provision Current WI OCI Hours of operation, wait times and availability of afterhours care must reflect the usual practice in the local area 14 7

8 Feb 27, 2015 Exchange Rules for 2016 Feb 20, 2015: Final Issuer Guidance for 2016 HHS continues to take great interest in ensuring strong network access HHS is aware that the NAIC has formed a workgroup that is drafting a model act relative to network adequacy and will await the results of this workgroup before proposing significant changes to network adequacy. 8

9 NAIC DISCUSSIONS National Association of Insurance Commissioners Network Adequacy Subgroup J.P. Wieske, Chair Rebecca Horne Peg Brown Christina Goe Martin Swanson Kim Everett Gayle Woods Linda Johnson Chlora Lindley Myers Molly Nollette Wisconsin California Colorado Montana Nebraska Nevada Oregon Rhode Island Tennessee Washington NAIC - Topics of discussion - Any willing provider is not on the table - Mileage/travel times, including use of telehealth and centers of excellence - Surprise bills costs to consumers for out of network; tiering of providers by insurers; balance billing; out-ofnetwork practitioners working in the in-network hospital - Insurance regulator role in monitoring adequacy of networks through access plans submitted by insurers and complaints - Quality of network - Consumer information/provider directories 18 9

10 WHA NETWORK ADEQUACY COUNCIL (NAC) Working group that will develop a recommended approach to addressing member concerns about network adequacy. Taking a deliberative approach, the group will assess the current regulatory environment and use research and data to draw conclusions. Concerns appear to be the result of changes exacerbated by the ACA and the insurance exchange implementation, but the group may address issues related to the market outside of the exchange as well. 10

11 NA GUIDING PRINCIPLES Transparency and Consumer Engagement. Provider networks must be exceptionally clear to consumers so they can make informed decisions at the point of choosing a health plan. Consumers must have the ability to determine which providers are in the network and which are accepting new patients. Individuals must be prudent buyers of health care services, availing themselves of information to purchase health care based on demonstrated quality and efficiency. Choice. Consumers must have access to a choice of insurers and providers. Initiatives must be driven by their ability to maximize competition and choice, and minimize administrative costs. The market must maximize choice for all participants, be accessible and attractive, and ensure fair competition. Accessibility. Consumers must have access through their health insurance to health care providers that meet their needs in a manner that reflects the usual and/or improved practices and standards of care in their community. NA GUIDING PRINCIPLES Affordability and Cost Effectiveness. Network adequacy standards must not result in unaffordable health insurance costs. Consumers must have an appropriate balance of adequate networks and choice of plans. Feasibility. Venues for network adequacy concerns to be raised and addressed must be clearly identified. Options for addressing network adequacy must consider the unique aspects of Wisconsin s health care markets and account for the benefits and costs to all stakeholders including consumers, providers, insurers, and taxpayers. 11

12 WI SPECIFIC ISSUES Out of network providers/practitioners working in the in network hospital Health plans not offering contracts to any hospital within the county Health plan offers contract at Medicaid rates Network listings/consumer information about providers is not displayed consistently across all providers in network Overall, lack of consumer understanding Tiering issues 12

13 What path should you follow if you have a NA issue? Some ideas: 1. Engage in discussions with the insurer (contract terms?) 2. Talk to consumers/employers. Consumers/employer submit questions/concerns to the insurer 3. Ensure the practitioner is in compliance with any statutory/scope requirements 4. Determine if Medicaid/non-Medicaid 5. Submit consumer complaints to appropriate agency. 6. Submit provider complaint to appropriate agency 25 Upcoming Landmarks Along the Path Additional Communication with OCI Summer 2015 Medicaid Managed Care Proposed Rule Comments due July 27, 2015 NAIC to complete its work Summer/Fall 2015 HHS to adopt new NA standards for Exchange Marketplace after NAIC work, likely in advance of Possibility for state level regulatory discussion? Fall 2015 Winter 2016 at earliest

14 The question is not whether or not change and challenge are going to happen. They are. The question is, when they do happen, how are we going to choose to look at them, contextualize them, and navigate them? Jeffrey R. Anderson, The Nature of Things - Navigating Everyday Life with Grace