Network Adequacy and Essential Community Providers

Transcription

1 Network Adequacy and Essential Community Providers April 10, 2015 Standing Advisory Committee Meeting A service of Maryland Health Benefit Exchange

2 Agenda A BRIEF OVERVIEW Federal Requirements National Association of Insurance Commissioners (NAIC) Maryland Requirements National Data Sources 2

3 Federal Requirements

4 Federal Requirements Affordable Care Act (ACA) ACA Regulations Network Adequacy Essential Community Providers (ECPs) Federally-facilitated Marketplace (FFM) Requirements 4

5 ACA Requirements ACA 1311 Requires the Secretary the Department of Health and Human Services (HHS) to establish criteria for certification of qualified health plans (QHPs), including: Ensuring a sufficient choice of providers Providing information on the availability of in-network and out-of-network providers Including ECPs within plan networks 5

6 Network Adequacy Regulations 45 CFR Network Adequacy A QHP issuer must ensure that the provider network : Includes ECPs Is sufficient in number and types of providers, including mental health and substance abuse, 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 6

7 Network Adequacy Regulations continued 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. A QHP issuer must publish an up-to-date, accurate, and complete provider directory, in a manner easily accessible to enrollees. The directory must include: Which providers are accepting new patients Provider s location Contact information Specialty Medical group Any institutional affiliations 7

8 ECP Regulations 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. This standard will be modified after January 1,

9 ECP Regulations continued 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 lowincome, medically underserved individuals in the QHP's service area, in accordance with the Exchange's network adequacy standards. Effective January 1, 2016, this standard will be modified. Broader Definition of ECP for

10 FFM Requirements Regulations lay out additional standards for issuers in the FFE For 2016, 30% of available ECPs in each plan s service area must participate in the provider network If guidelines are not met, the issuer must include a satisfactory narrative justification as part of its application 11

11 NAIC

12 NAIC In 1996, the NAIC adopted the Managed Care Network Adequacy Model Act Managed care plans are required to maintain networks that ensure access to services without unreasonable delay Requirements of the Model Act include: Allowing an enrollee to go out-of-network at no additional cost if a covered benefit is not available in-network Monitoring providers to ensure all covered benefits are delivered Filing an access plan with the state insurance commissioner Including providers who treat high-risk populations The model act does not include specific quantitative standards 13

13 NAIC Draft Model Act The NAIC Workgroup is reviewing and considering revisions to the Model Act to comply with ACA requirements The NAIC released a draft model act in November 2014 Health Benefit Plan Network Access and Adequacy Model Act The Draft Model Act includes: A requirement that insurers make their QHP provider directories available online, updated monthly More detailed requirements for allowing an enrollee to go outof-network if a covered benefit is not available in-network 14

14 Maryland Requirements

15 Insurance Requirements COMAR Under the Insurance Administration regulations, carriers must maintain provider panels that are sufficient in numbers and types to meet the health care needs of enrollees without unreasonable delay. 16

16 MHBE QHP Standards On March 17, 2015, the MHBE Board approved 2016 plan certification standards The 2016 network adequacy standards require the provider list to be current (updated at least twice a month), accurate, and complete. Carriers provide data to CRISP for inclusion in the provider directory The 2016 network adequacy standards also require plans to describe their networks and attest that they meet the reasonable access standards. The standards require MHBE to work with Hilltop to analyze any helpful data; seek input from the Standing Advisory Committee and Medicaid; and develop recommended metrics for network adequacy standards and ECP engagement adequacy standards for 2017 plans. 17

17 National Data Sources

18 National Provider Lists American Medical Association Physician Master File Health Resources and Service Administration (HRSA) Area Health Resource File National Ambulatory Medical Care Survey (NAMCS) Physician Workflow Supplement 19

19 Medical Expenditure Panel Survey (MEPS) MEPS household component includes questions that measure access to care, an indirect measure of network adequacy, including: Whether each member has a medical provider that serves as the usual source of care Reasons a member does not have a usual source of care Problems household experienced in obtaining needed care 20

20 Kaiser Health Tracking Poll: February 2014 A survey by the Kaiser Family Foundation of consumers found that potential exchange enrollees were more likely to prefer less costly plans with more narrow networks 54 percent of the people most likely to enroll in exchanges preferred a less costly narrow network plan, and only 34 percent of this group preferred a broad network When those who preferred a narrow network were presented with the possibility of not being able to use their current providers, the share that preferred this option dropped from 54 percent to 35 percent The survey showed that cost is very important to consumers. However, consumers are also reluctant to give up their current providers for a less expensive plan. Hamel, L., Firth, J., & Brodi, M. (2014, February 26). Kaiser health tracking poll: February Retrieved from 21

21 McKinsey Study The McKinsey Center for U.S. Health Reform conducted a study of all insurers filing on the 2014 exchanges. Study included 282 issuers with 20,818 plans and all 4,773 acute care hospitals in the U.S. Study found that: Plans with broad networks were available to 90% of the QHPeligible population Plans with narrow networks were available to 92% of the QHP-eligible population Bauman, N., Coe, E., Ogden, J., & Parikh, A. (2014, June). Hospital networks: Updated national view of configurations on the Exchanges. Retrieved from 22

22 McKinsey Study continued Narrow networks made up 48 % of all exchange networks in the U.S. Broad network plans had a median increase in premiums of 13 to 17 percent. 70% of the lowest price plans are built around narrow networks. Bauman, N., Coe, E., Ogden, J., & Parikh, A. (2014, June). Hospital networks: Updated national view of configurations on the Exchanges. Retrieved from 23