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Making Network Adequacy Progress in 2015 Claire McAndrew, Private Insurance Program Director.

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Presentation on theme: "Making Network Adequacy Progress in 2015 Claire McAndrew, Private Insurance Program Director."— Presentation transcript:

1 Making Network Adequacy Progress in 2015 Claire McAndrew, Private Insurance Program Director

2 FamiliesUSA.org Recent Federal Activity Draft Proposed Rule on Benefit and Payment Parameters for 2016 Encourages transition period for new enrollees Includes some provider directory standards for all marketplaces: Must include: whether accepting new patients, location, contact info, specialty, medical group, and any institutional affiliations Must be able to view current directory on the insurer’s site through a clearly identifiable link or tab and without creating or accessing an account or entering a policy number If insurer has multiple networks, public must be able to easily discern which providers participate in which networks.

3 FamiliesUSA.org Recent Federal Activity Draft 2016 Letter to Issuers in the FFM Similar to this year’s process Network templates HHS review focuses on: Hospitals Mental health providers Oncology providers Primary Care Providers Dental providers, if applicable

4 FamiliesUSA.org What more can be done? Tangible protections for consumers: Timely Access to Care Geographic Access: Time and Distance Standards Right to go out of network if no provider can meet needs

5 FamiliesUSA.org What more can be done? Timely Access to Care Washington: health plans must demonstrate that enrollees can get appointments with primary care providers for non- preventive services within 10 business days of requesting them. Plans must establish that enrollees can get appointments with specialists (when referred) within 15 business days for non- urgent services.

6 FamiliesUSA.org What more can be done? Time and Distance Standards Vermont: Standards for marketplace plans and regulations for all managed care plans require that travel times for enrollees to reach in- network providers “under normal conditions from their residence or place of business, generally should not exceed:” 30 minutes to a primary care provider; 30 minutes to routine, office-based mental health and substance abuse services 60 minutes for outpatient physician specialty care; intensive outpatient, partial hospital, residential, or inpatient mental health and substance abuse services; laboratory services; pharmacy services; general optometry services; inpatient care; imaging services; and inpatient medical rehabilitation services 90 minutes for kidney transplantation; major trauma treatment; neonatal intensive care; and tertiary-level cardiac services, including procedures such as cardiac catheterization and cardiac surgery

7 FamiliesUSA.org What more can be done? Right to go out of network if no provider can meet needs Delaware: If managed care plans have “an insufficient number of providers that are geographically accessible and available within a reasonable period of time to provide covered health services to enrollees,” these plans must provide coverage for enrollees to see out- of-network providers for those services; No “balance billing.” Other protections to consider Rules about what providers must be included Stronger essential community provider standards Provider-to-patient ratios Protections to ensure access for diverse populations Standards for accessible hours

8 FamiliesUSA.org Provider Directory Standards States often rely on update frequency requirements Other options Require plans to prominently list address on directories used solely for public to notify plan of directory inaccuracies; require plans to investigate the reports and modify directories in response. A requirement that plans internally audit their directories and modify directories based on audit findings A requirement that plans contact providers listed as in network who have not submitted claims within the past year (or other time frame) to determine whether the provider still intends to be in network and modify directory accordingly (NJ standard). A requirement that plans honor provider directory information such that if a consumer relies on materially inaccurate information from a directory indicating that a provider is in-network and receives care from that provider, the consumer is held harmless

9 FamiliesUSA.org How do we get there? Information gathering to build the case Story collecting (from consumers, assisters, etc.) Secret shopper studies of directories Insurance department data (complaints, OON care) Bring your evidence and asks to the decision-makers State insurance regulators (insurance commissioner/ department) State legislators State marketplace board members, directors and staff Federal HHS staff/ Regional Directors Members of Congress

10 FamiliesUSA.org How do we get there? Other tips Strategically partner with providers, including ECPs Strategically involve media

11 1201 New York Avenue, NW, Suite 1100 Washington, DC main / fax Contact: Claire McAndrew Key Resources: Standards for Health Insurance Provider Networks: Examples from the States: provider-networks-examples-stateshttp://familiesusa.org/product/standards-health-insurance- provider-networks-examples-states Network Adequacy and Health Equity: Improving Private Health Insurance Provider Networks for Communities of Color: networks-communities-color networks-communities-color Network Adequacy 101: An Explainer:


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