Making Plans Meet the Need: Advocating for Adequate Networks

1. Making Plans Meet the Need: Advocating for Adequate Networks Anna Odegaard Health Policy Analyst SEIU Healthcare Minnesota

2. Overview • The Landscape • Why narrower networks now? • Pros and cons of narrow networks • ACA requirements • Advocacy in Minnesota • Process • Goals and Outcome • Moving Forward • Show us the data

3. The Landscape

4. Why Narrower Networks Now? • Exchanges promoting competition on price • Fewer ways for carriers to distinguish products • Overall trend toward payment and delivery reform

5. Narrow Networks Lower Premiums When 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.

6. Narrow Networks Better Value Carriers may: • Exclude higher-cost providers from their network, especially those not perceived to deliver good value • Design a network to promote care coordination • Design a network around an innovative payment and delivery structure

7. Narrow Networks Barriers to Access • Major influx of enrollees due to ACA reforms • Pent-up demand for healthcare services • Different utilization patterns for new populations • Narrower 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

8. ACA Requirements For 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)

9. ACA Requirements What is “Sufficient”? • Geographic Access • Timely Access • Choice of Providers • Continuity of Care

10. Advocacy in Minnesota

11. Vehicles for Advocacy • Health Insurance Exchange Advisory Task Force • Legislative Process • MNsure Board and Advisory Committees

12. Identifying Allies Healthcare Providers • MN Hospital Association • MN Medical Association • Community Health Centers Advocacy organizations • TakeAction Minnesota • Legal Aid • Minnesota Budget Project • AARP • LGBTQ Health Roundtable Patient Advocacy Orgs. • MN Cancer Society • MN Heart Assoc. Labor Organizations Small Business Organizations Elected Officials State Agency Staff

13. Articulating Goals 1. Draw on existing network requirements: • HMOs • Public Healthcare Programs • Other states 2. Look at comments on CMS proposed regulations. 3. Talk to agency staff who enforce existing standards.

14. Goals and Outcomes

15. 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

16. Coalition Recommendations Timely 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

17. Coalition Recommendations Continuity 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.”

18. Task Force Recommendations “ Generally use the State’s existing standards for HMOs related to network adequacy…” • Geographic Access Standards • Timely Access Standards (but not Appointment Wait Times) • No Continuity of Care or Remedy language

19. Final Network Adequacy Standards Geographic 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.

20. Final Network Adequacy Standards Network 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 days per week, within the network area; (2) a sufficient number of primary care physicians have hospital admitting privileges at one or more participating hospitals within the network area so that necessary admissions are made on a 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 a given provider, these services shall be available and accessible; and (6) the network has available, either directly or through arrangements, appropriate and sufficient personnel, physical resources, and equipment to meet the projected needs of enrollees for covered health care services.

21. Moving Forward

22. Show us the Data What 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?

23. Show us the Data Sources of data: • Federal requirements for data collection by Exchanges • State data collection systems • New state data collection systems specific to QHPs • Other?

24. Anna Odegaard anna.odegaard@seiuhcmn.org 612-532-3723