Making Plans Meet the Need: Advocating for Adequate Networks

Anna OdegaardHealth Policy Analyst

SEIU Healthcare Minnesota

Overview1. The Landscape

Why narrower networks now? Pros and cons of narrow networks ACA requirements

2. Advocacy in Minnesota Process Goals and Outcome

3. Moving Forward Show us the data

The Landscape

Why Narrower Networks Now?Exchanges

promoting competition on price

Fewer ways for carriers to distinguish products

Overall trend toward payment and delivery reform

Narrow NetworksLower PremiumsWhen carriers contract with a smaller network of providers,

they may offer providers more patient volume in exchange for lower reimbursement rates, which they can pass on as lower premiums.

Narrow NetworksBetter Value

Carriers may:Exclude higher-cost providers from their network, especially

those not perceived to deliver good valueDesign a network to promote care coordination Design a network around an innovative payment and delivery

structure

Narrow NetworksBarriers to AccessMajor influx of enrollees due to ACA reformsPent-up demand for healthcare services Different utilization patterns for new populationsNarrower networks may compound other barriers to

access like lack of transportation options, language barriers, inflexible work hours, etc.

No system for monitoring access to providers

ACA RequirementsFor each Qualified Health Plan, issuers must:

1. Maintain 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.

2. Include a sufficient number and geographic distribution of Essential Community Providers, 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.(§ 156.230 and §156.235 from the Exchange final rule issued March 27, 2012)

ACA RequirementsWhat is

“Sufficient”?1. Geographic Access2. Timely Access3. Choice of Providers4. Continuity of Care

Advocacy in Minnesota

Vehicles for Advocacy1. Health Insurance Exchange Advisory Task Force2. Legislative Process3. MNsure Board and

Advisory Committees

Identifying AlliesHealthcare Providers

MN Hospital AssociationMN Medical AssociationCommunity Health Centers

Advocacy organizationsTakeAction MinnesotaLegal AidMinnesota Budget ProjectAARPLGBTQ Health Roundtable

Patient Advocacy Orgs.MN Cancer SocietyMN Heart Assoc.

Labor Organizations

Small Business Organizations

Elected Officials

State Agency Staff

Articulating Goals1. Draw on existing network

requirements:

HMOsPublic Healthcare

ProgramsOther states

2. Look at comments on CMS proposed regulations.

3. Talk to agency staff who enforce existing standards.

Goals and Outcomes

Coalition Recommendations

Geographic Access

Not more than: 30 miles/30 minutes to primary care provider 60 miles/60 minutes to specialty care provider 60 miles/60 minutes to dental care provider

Coalition RecommendationsTimely Access

All Carriers shall have: Sufficient personnel, physical resources, and equipment to meet the projected

need for covered services Written guidelines to assess the capacity of each network to provide timely

access to care Written appointment scheduling guidelines based on type of health care service

Appointment Wait Times: Appointments for primary care within 45 days of request Appointments for urgent care within 24 hours of request Appointments for routine dental care within 60 days of request Appointments for urgent dental care within 48 hours of request

Coalition RecommendationsContinuity of Care Remedy language

“Health carriers shall ensure that enrollees may access out-of-network services at the same level of cost-sharing as in-network services if those services are not available from in-network providers on a timely basis.”

Task Force Recommendations“ Generally use the State’s existing standards for HMOs related to network adequacy…”

Geographic Access StandardsTimely Access Standards (but not Appointment Wait Times)No Continuity of Care or Remedy language

Final Network Adequacy StandardsGeographic Access:

Primary care; mental health services; general hospital services. The maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the nearest provider of each of the following services: primary care services, mental health services, and general hospital services.

Other health services. The maximum travel distance or time shall be the lesser of 60 miles or 60 minutes to the nearest provider of specialty physician services, ancillary services, specialized hospital services, and all other health services not listed in subdivision 2.

Limited-scope pediatric dental plans must ensure primary care dental services are available within 60 miles or 60 minutes' travel time.

Final Network Adequacy StandardsNetwork adequacy:Each designated provider network must include a sufficient number and type of providers, including providers that specialize

in mental health and substance use disorder services, to ensure that covered services are available to all enrollees without unreasonable delay. In determining network adequacy, the commissioner of health shall consider availability of services, including the following:

(1) primary care physician services are available and accessible 24 hours per day, seven daysper week, within the network area;

(2) a sufficient number of primary care physicians have hospital admitting privileges at oneor more participating hospitals within the network area so that necessary admissions are made ona timely basis consistent with generally accepted practice parameters;

(3) specialty physician service is available through the network or contract arrangement;(4) mental health and substance use disorder treatment providers are available and accessible

through the network or contract arrangement;(5) to the extent that primary care services are provided through primary care providers other

than physicians, and to the extent permitted under applicable scope of practice in state law for agiven provider, these services shall be available and accessible; and

(6) the network has available, either directly or through arrangements, appropriate andsufficient personnel, physical resources, and equipment to meet the projected needs of enrolleesfor covered health care services.

Moving Forward

Show us the DataWhat do we need to know?What networks do people choose?What role do networks play in people’s choice?How well do people understand their network?Do network restrictions present a barrier to access?How much out-of-network provider use occurs?What specific services are sought out-of-network?

Show us the DataSources of data:Federal requirements for data collection by ExchangesState data collection systemsNew state data collection systems specific to QHPsOther?

Anna Odegaard

anna.odegaard@seiuhcmn.org612-532-3723