Recommendations From Staff Relating to Network Adequacy and Accessibility

Transcription

1 Recommendations From Staff Relating to Network Adequacy and Accessibility Background In 2013, the National Association of Insurance Commissioner s (NAIC s) Regulatory Framework (B) Task Force was charged with reviewing NAIC existing models related to health insurance to determine whether they needed to be amended in light of all the changes made by the federal Affordable Care Act (ACA). During that review process, it was clear that revising the Managed Care Plan Network Adequacy Model Act (#74) was a priority for regulators, health carriers and consumers, in part because of a pending possible one-size-fits-all national standard approach being considered by the federal Center for Consumer Information and Insurance Oversight (CCIIO). Realizing that a federal one-size-fits-all national standard would not benefit consumers or health carriers and that state insurance regulators are best positioned to balance cost, access and geographic considerations when developing network adequacy standards to ensure networks are sufficient so that consumers can access promised services without unreasonable travel or delay, the Regulatory Framework (B) Task Force made revising Model #74 an immediate priority. The Network Adequacy Model Review Subgroup was formed, and in March of 2014, work began on revising the model. At the 2015 Fall National Meeting of the NAIC, the full NAIC membership adopted the revisions to Model #74, now called the Health Benefit Plan Network Access and Adequacy Model Act. Once a model is adopted at the NAIC level, the member states are then charged to try to adopt the model s standards themselves. In spring of 2016, Commissioner Wayne Goodwin formed the Network Adequacy Working Group (NAWG) made up of various stakeholders to help advise the Department on our approach to adopting the revised model and it s standards in North Carolina. The NAWG was formed of three subgroups one with consumer advocates, one with provider groups, and one with health insurers. All three subgroups worked through the summer reviewing specific sections of the model and developing recommendations for how NCDOI should approach various aspects of network adequacy and accessibility regulation. Additionally, the Department sought public input, including additional independent input and comment from NAWG members, relating to network adequacy and accessibility standards and regulation. Those recommendations and public comments were considered by subject matter experts in the Life & Health Division and other Department personnel experienced with the subject Network Adequacy Recommendations Page 1 Rev

2 matter and was reviewed in light of current regulation and statutes and the Department s current regulatory approach to network adequacy. The following is a list of final recommendations from Department staff. Model Act Section 5 Network Adequacy This section pertains to network sufficiency, how network sufficiency is determined, and who is to determine network sufficiency. The goal of the standards is that a health carrier providing a network plan provides and maintains a network that is sufficient in the number and appropriate types of providers to assure that all covered services to covered persons will be accessible without unreasonable travel or delay. 1) Establish measurable numeric (quantitative) minimum standards to define network adequacy using at least some of the following: a) Distance travelled varied by population distribution (use time for travel and/or distance travelled standards); b) Use population density and providers by geography in standards; c) Use population types (metro, micro, rural, etc.) to help establish standards by geography d) Use a geographic standard which does not solely rely upon county since medical referral and access patterns frequently cross county lines. e) Provide for DOI discretion in applying standards when unforeseen situations arise, to permit for innovation, to accommodate needs to protect and service customers, or to increase competition. Related Current Statutory/Regulatory Citations: T11: , Related Model Act Reference(s): Sections 5.A, 5.B, 5.D, 5.E, 5.F. 2) Establish standards specific to network products that reflect the network type and establish that all network tiers of a tiered product must independently satisfy the adequacy and accessibility standards. Related Current Statutory/Regulatory Citations: T11: , Related Model Act Reference(s): Sections 5.A, 5.B, 5.D, 5.E, 5.F., 6.F 3) Establish standards by provider type with an emphasis on primary care, but still requiring delineation of standards by provider type similar to what health carriers reported to NCDOI in the Managed Care report(repealed). Related Current Statutory/Regulatory Citations: T11: , Related Model Act Reference(s): Sections 5.A, 5.B, 5.D, 5.E, 5.F. Network Adequacy Recommendations Page 2 Rev

3 4) Establish standards around which providers to count, and that recognize how less traditional providers can be counted to establish adequacy such as physician extenders and telehealth initiatives. Recognize how care is provided and how that is evolving, such as the use of non-traditional settings. Related Current Statutory/Regulatory Citations: T11: , Related Model Act Reference(s): Sections 5.A, 5.B, 5.D, 5.E, 5.F. 5) Establish standards for adequacy and accessibility that recognize certain providers traditional role in serving underserved populations as well as those providing mental health and substance use services. a) Consider whether requiring inclusion of Essential Community Providers should apply (currently is federal requirement for on exchange health carriers only). Related Model Act Reference(s): Sections 2, 5.A, 5.B, 5.D, 5.E, 5.F. 6) Establish consumer transparency standards that include: a) Requirement that consumer documents include a better description of how the network functions; something more illuminating than what is currently required in statute, and/or dictate what is disclosed and how under current statute. (1) Include good layman s explanation of tiered products that is provided pre- and post-enrollment. b) Requirement that consumer documents explain the provisions of (d) in a better manner and specifically include instructions on how to request out-of-network care be considered as in-network under (d). c) Requirement that health carriers explain or make available to the consumer their definition of reasonable access without unreasonable delay as found in (d). Related Current Statutory/Regulatory Citations: G.S , , T11: , Related Model Act Reference(s): Section 5.C 7) Establish standards that use existing standards such as Medicare Advantage or Medicaid OR establish NC specific standards without considering federal requirements. Related Model Act Reference(s): Sections 5.A, 5.B, 5.D, 5.E, 5.F. Network Adequacy Recommendations Page 3 Rev

4 8) Consider the unique implementation and applicability issues when considering application to dental and vision products, thereby consider adopting specific standards for these products. Related Model Act Reference(s): Sections 4.B., 7.J.1 and drafting notes in Sections 3, 5, 6, 7, 8 and 9 9) Do not establish standards that require a health carrier to accept any willing provider into its network as such provisions are counter to the purposes of networks and make creating network products with better pricing virtually impossible. Related Current Statutory/Regulatory Citations: T11: (e) Related Model Act Reference(s): Section 6.F.b.ii Model Act Section 6 Requirements for Health Carriers and Participating Providers (i.e. provider contracting) This section contains standards relating to contracting between health carriers and providers, including standard provisions and prohibitions on certain types of unfair contractual provisions. This section also includes standards relating to continuity of care and transparency requirements relating to how a health carrier selects providers for networks (including tiered networks). 1) Establish a standard that requires health carriers to clearly communicate to consumers and providers how a tiered network is established, and requires active communication between the health carrier, providers and consumers and does not rely upon passive communication. The standards should include timeliness of updates, timeliness of delivery of notices, and the readability of the information/explanation. a) Include establishment of standard terminology and definitions which health carriers must use in contracts, policy forms, certificates/eocs, and advertising in order to provide consistency across the market for providers and consumers. b) Standard which require for publication of health carriers criteria for participation in a network, but should also be flexible in relation to providing information on tiering criteria in order to not hinder health carriers ability to establish new and innovative networks and products. Related Current Statutory/Regulatory Citations: G.S , , , T11: Related Model Act Reference(s): Sections 5.F, 6.F, 6.G, Network Adequacy Recommendations Page 4 Rev

5 2) Protect consumers by extending the HMO hold harmless provision (found in G.S ) so that it applies to PPOs health carrier and products too and, to the degree it is not clear, affirm it applies to POS products. Related Current Statutory/Regulatory Citations: G.S , , , T11: Related Model Act Reference(s): Section 6.B. 3) With regard to Section 6.G. of the model act, provide the insurance commissioner with authority to approve the health carrier s criteria for credentialing and provider participation, including tiering. Related Current Statutory/Regulatory Citations: G.S , T11: Model Act Reference(s): Section 6.G 4) Continuity of Care Provisions the HMO (only) continuity of care provision should be extended to POS and PPO health carriers and products. a) Continuity of care should last for 90 days b) Decisions relating to continuity of care should be clearly included as appealable decisions under Appeal/Grievance/ER requirements. c) Revise COC provision to focus on serious conditions and review federal provisions for alignment where it makes sense. d) Notices to consumers should only be required to be provided at the practice level and not the individual doctor level, especially in regard to academic centers and hospitalbased providers (or only apply to community based providers). Related Current Statutory/Regulatory Citations: G.S , T11: , Related Model Act Reference(s): Sections 5.F, 6.L, 5) Adopt standards found in Section 6.F.3(a) (of the Model Act) relating to non-discrimination in selection and tiering standards to assure that providers are not discriminated against because of the population or area they serve. Related Model Act Reference(s): Section 6.F.3 Network Adequacy Recommendations Page 5 Rev

6 6) Prohibit provisions in provider contracts between a health carrier and provider that indicate a provider agrees to participate in ALL network products offered by the health carrier. a) Require the health carrier to provide a notice to a provider when a provider is being removed from a select network. b) Require the health carrier to include in the provider contract (at issuance and whenever there is any change to the networks and/or products under the contract) to include a specific listing of all the networks and products the provider has agreed to participate upon. Related Current Statutory/Regulatory Citations: T11: (removal from a network) Related Model Act Reference(s): Section 6.T.2 7) Consider the unique implementation and applicability issues when considering application to dental and vision products, thereby consider adopting specific standards for these products. Related Model Act Reference(s): Sections 4.B., 7.J.1 and drafting notes in Sections 3, 5, 6, 7, 8 and 9 Model Act Section 7 Requirements for Participating Facilities with Non- Participating Facility-based Providers & Section 8 Disclosure and Notice Requirements These sections set out requirements for addressing one narrow aspect of the surprise bill issue situations where a covered person receives services at a participating facility from a nonparticipating facility-based provider, and for the development of a written disclosure or notice to be provided to covered persons at the time of pre-certification that there is the possibility that the covered person could be treated at the participating facility by a health care professional who is not in the same network as the covered person s network. 1) More education and disclosure around the provisions of (d) is necessary. Establish (or build upon existing) standards that require disclosure to consumers through policy forms, certificate/eocs, and other communications which explain what the statute requires and provides. a) Research feasibility of new interpretation/application of G.S (d), , T11: and T11: and whether they provide enough authority to require better disclosure without adopting new statutes or regulations. Network Adequacy Recommendations Page 6 Rev

7 b) Propose amendment to which requires specific disclosure that in the case of balance billing by a facility-based non-participating the consumer should request a review of such charges under (d). c) Establish a process by which requests under #2 are established by the health carrier and follow similar time frames as found in UR requirements. d) Require health carriers to include a provision in contracts with facilities that the ancillary providers at the hospital must disclosure that they do not participate in the network to consumers. Related Current Statutory/Regulatory Citations: G.S , , T11: , Related Model Act Reference(s): Sections 7, 8 2) Recognizing that many of the standards in the Model Act require providers to do certain things and that NCDOI does not regulate providers, provide the following recommendation to the state regulating bodies for facilities and facility-based providers. a) Establish standard that requires a facility to provide notice to member to inform them of obligations and the possibility of out-of-network billing and what that means. Consider how to provide consumers with recourse if a provider does not give the notice in this recommendation and/or a provider balance bills inappropriately. b) Require disclosure by hospital ancillary providers that they do not participate in the network and the notice should be made in advance of receiving services, or require health carriers to include similar provisions in their provider contracts with participating facilities. c) Establish a penalty for providers who fail to provide the notice as required. Related Model Act Reference(s): Sections 7, 8 3) Do not establish a requirement that a health carrier accept assignment of benefits in all cases, as to do so would remove one incentive health carriers have to encourage participation by providers in networks. Related Model Act Reference(s): N/A 4) Do not weaken the standards and protections already found in NC s laws. Related Current Statutory/Regulatory Citations: G.S , , T11: , Related Model Act Reference(s): N/A Network Adequacy Recommendations Page 7 Rev

8 5) Consider the unique implementation and applicability issues when considering application to dental and vision products, thereby consider adopting specific standards for these products. Related Model Act Reference(s): Sections 4.B., 7.J.1 and drafting notes in Sections 3, 5, 6, 7, 8 and 9 Model Act Section 9 Provider Directories This section establishes requirements for health carriers related to electronic and print provider directories. This section also describes what general and specific information must be included in both the print and electronic directories to enable covered persons and prospective covered persons to select a health benefit plan most appropriate to their needs. It also includes a requirement for health carriers to update their provider directories at least monthly and to periodically audit them for accuracy. 1) Establish a standard that requires provider directories to be updated no less frequently than monthly. a) Include flexibility for health carriers on updates to permit time for internal audits to assure that information that is published has been verified; require health carriers to contact participating providers for whom they have not received claims in the past 12 month period to confirm status. Related Current Statutory/Regulatory Citations: G.S Related Model Act Reference(s): Section 9.A 2) Establish a standard that requires directories to include: (refer to Model Act for suggestions modify as necessary) a) Whether a provider is accepting new patients b) If a provider has accessibility for people with disabilities c) What networks a provider and products participates under d) Disclosure in prominent way that the directory may change and that an individual should contact the health carrier and/or provider for up-to-date information on participation. e) Disclosure of the health carrier s process for updating the directory, and how information is evolving, and why checking with provider is critical to establish participation. Related Current Statutory/Regulatory Citations: G.S Related Model Act Reference(s): Section 9.B Network Adequacy Recommendations Page 8 Rev

9 3) Establish authority for NCDOI to conduct routine audits of provider directories. Related Model Act Reference(s): N/A 4) Establish requirement via contracting that a provider provide notice to a health carrier within a certain time frame when the provider pulls out of a network. Consider what would be appropriate penalties should a provider fail to give notice. Related Model Act Reference(s): N/A 5) Consider the unique implementation and applicability issues when considering application to dental and vision products, thereby consider adopting specific standards for these products. Related Model Act Reference(s): Sections 4.B., 7.J.1 and drafting notes in Sections 3, 5, 6, 7, 8 and 9 6) Research the possibility of: a) Adopting a special enrollment period for consumers who relied upon a published directory to select a plan only to find that a key provider practice does not participate; the possibility of b) Adopting a requirement that on-line directories be searchable by network types and products types and make that information is clear and granular. c) Adopting a requirement that directories to explain the difference in broad and narrow (select) networks to best assure that the directory helps a consumer identify a good network fit thereby helping consumer navigate the system more effectively. d) Allowing consumers/customers to provide corrections to directories Related Model Act Reference(s): Sections 9A, 9B, 9.C 7) When a provider is dropped from a network (through no action of the provider) and/or moved to a less favorable tier, have Continuity of Care provisions apply. Related Current Statutory/Regulatory Citations: G.S , T11: , Related Model Act Reference(s): N/A Network Adequacy Recommendations Page 9 Rev

10 Additional specific recommendations from Stakeholders which align with or compliment Staff Recommendations Section 5 Establish standards for adequacy and accessibility that recognize certain providers traditional role in serving underserved populations as well as those providing mental health and substance use services including requiring a minimum number of full-time providers to meet the needs of individuals with limited English proficiency. (ACS/CAN) In tiered networks, all care must be accessible under all in-network tiers, and tiers cannot be designed to discourage persons with certain diseases or conditions from choosing to enroll in a plan. (ACS/CAN, AHA/ASA) Propose research to determine whether appointment wait-times should be part of network adequacy and accessibility standards, and if so, what standards to apply and how. (NCJC, AHA/ASA, NMSS, ACS/CAN) Apply adequacy and accessibility standards prospectively for the upcoming year. (BCBSNC) Use the same breakdown of providers as CMS for adequacy standards. (BCBSNC) Allow for exceptions when there are extreme situations, such an application of an adjusted standard in special situations. (BCBSNC) Establish a system which has health carrier demonstrate adequacy on an annual basis. Supports a standard (measurement?) of appointment wait times but would not support a standard that is one-size-fits all or does not permit for discretion and flexibility; would encourage a process which allows NCDOI to intervene on behalf of a consumer when warranted or to have an health carrier allow out-of-network access at in-network cost sharing. (BCBSNC) Section 6 Continuity of Care Provisions the HMO (only) continuity of care provision should be extended to POS and PPO health carriers and products require adequate notice to a consumer that a provider is leaving a network (involuntarily) and consider how Continuity of Care fits in to this issue. (NMSS) Continuity of Care Provisions - Require that health carriers have a process that will permit a consumer to ask for a longer COC scenario in special circumstances. (AHA/ASA) Flexibility in type of networks that can be created to allow for innovation, while retaining ability to continue to be appropriately tough in contractual negotiations and permit refusal to contract. (BCBSNC) Require an adequate networks to be defined to include contracting with ECPs (BCBSNC). Continuity of Care Provisions require notice to patients who are seen regularly, not all patients. (BCBSNC) Network Adequacy Recommendations Page 10 Rev

11 Continuity of Care Provisions require notice be given by providers facilities and physicians. (BCBSNC) Sections 7&8 None Section 9 Require all provider directories to be accessible online without login and/or account creation, and be available in print (with a caveat that printed directories do not have to be updated as frequently as electronic directories and printed directories shall include a version date and instructions for seeking up-to-date information). (NMSS, NCJC) Require that provider directories be written in plain language so that the average consumer is able to determine which providers are included in a plan s network. (ACS/CAN) General Comments Put standards in statutes to avoid lengthy and unpredictable regulation adoption process. (BCBSNC) Add provision which has COI assess the standards that are adopted and report to the General Assembly in 3 to 5 years. (BCBSNC) Keep consumer protections strong but don t make standards such that smaller, newer health carriers cannot meet them thereby hindering competition and new entrants to the markets. (BCBSNC) Do not use Medicare Advantage and/or Medicaid network adequacy standards as they do not take into account NC s special needs. (BCBSNC, but also echoed by the industry group in general) Network Adequacy Recommendations Page 11 Rev