Presentation - Families USA

Timely Access & Network Adequacy
The California Experience
Health Access California
January 2015
Health Access California
• California’s statewide healthcare consumer
advocacy coalition
• Created in late 1980s
• Fought for:
– 1990s: HMO Reform, Patient Bill of Rights
– Coverage Expansions: Medicaid, Employer,
– State Budget Battles
– The Affordable Care Act
California Market
• 38 Million Californians
• Medicare: 4.5 million
• Medicaid: 11.5-12.2 million
– Over 8 million in Medicaid Managed Care
• Department of Managed Health Care: 21-22
million, including Medi-Cal managed care
• California Department of Insurance: under 2
million (no recent data)
• Remaining uninsured: 2.7-3.8 million
California Context
• Two regulators
• Department of Managed Health Care
– Created in 1999, Legislation sponsored by Health
– Regulates PPOs, EPOs and HMOs
– Regulates coverage for 21-22 million Californians
• California Department of Insurance
– Elected Insurance Commissioner since 1988
– Regulates health insurance, including PPOs and EPOs
but not HMOs
– Regulates coverage for 2 million Californians
Foundational Concept
• Managed Care, Limited Networks, ACOs work
only if the consumer is guaranteed:
The Care You Need When You Need It at
In-Network Cost Sharing
– Not the care you want when you feel like it.
– Not the doctor you want but the care you need.
• What you need when you need it. At innetwork cost.
Network Adequacy
• Primary Care, Hospital Care:
– Geographic access: 15 miles, 30 minutes
– Provider ratios: 1/1200. Updated to add NPs, PAs
• Specialty care: the specialist you need at in-network
cost sharing. What the provider is paid is up to the plan
and the provider, not the consumer.
• If medically necessary care not available in network,
the health plan obliged to arrange it for consumer at
in-network cost sharing.
– Applies to all care but most relevant to highly specialized
care or care where timeliness is critical
• 1995: Wilm’s tumor: $500,000 fine
• Heart surgery
• Transgender Care
Timely Access to Care
• In 1975, law said:
”All services shall be readily available at reasonable times to
each enrollee consistent with good professional practice.”
• In 1997, Health Access sponsored AB497:
– same-day urgent care
– non-urgent care in ten days
– answer the phone in four minutes
• In 2010, regulations impose time-elapsed standards:
– 48 hours for urgent care
– Telephone triage within 30 minutes
– Non-urgent care:
• 10 days for primary care
• 15 for specialty
Balance Billing
Surprise! Consumers Owe Money!
• Cost sharing for emergency care:
– In-network cost sharing whether in-network or out of
network emergency care for PPOs/HMOs/EPOs
regulated by DMHC
– For health insurers, consumers pay out of network
cost sharing at out of network emergency rooms.
Pending regulations: see 2015 efforts
– Counts toward annual out of pocket limit for both
DMHC and Ca Department of Insurance
• Surprise bills: hospital-based physicians! Big
problem! See 2015 efforts
Out of Network Benefit
• Customary for PPO, No Statutory Standards
• Little Used:
– Cost for consumers higher, much higher
– Not count toward annual out of pocket limit
– If adequate network with timely access, should be
unnecessary to obtain needed care
• Does it let health insurers off the hook?
– If a consumer is encouraged to go out of network at
the consumer’s expense, does that let the HMO or
PPO off the hook for an adequate network?
Provider Directory
• California’s experience to date: What a mess!
• Non-routine surveys of Anthem and Blue
Shield in 2014:
– Directories 2-3 years old
– 25% or more of providers not correct!
• Medi-Cal managed care worse!
• Law designed for pre-Internet era and not as
good as the Yellow Pages
Recent Efforts
• 2014: SB964
– Annual reporting on network adequacy
– Annual reporting on timely access
– All products regulated by DMHC: group, individual,
Medicaid, Exchange
– Separate reports for separate networks
• Many commercial plans use different networks for Medicaid than
for commercial
• Some use different networks for individual market than for
employer market
• 2014: Covered California
– Big problems with narrow networks, inaccurate
provider directories:
– On narrow networks, we advocated, they acted.
– On provider directories, need legislation
2015 Efforts
• Provider Directory:
– Standardize format across plans/insurers
– Allow people to shop for Medicaid managed care,
exchange, off-exchange, group coverage
• Surprise bills at in-network facilities:
– Consumer pays in-network cost sharing unless
voluntarily consents to out of network provider
• Timely Access monitoring
• California Department of Insurance emergency
• Enforcement
– Complaints not enough
– Good standards meaningless unless regulator has survey
• Business interests of plans and providers different than
– sometimes plans/providers interest harmonize to
detriment of consumers: timely access
• ACA: brings into focus addl gaps/problems (provider
directory, standard formularies)
• Inherent tension between limited networks and access
• Rural areas: California: large geography, small % of
Advocacy Lesson
• When in doubt, ask yourself:
–Are Consumers Getting the Care They
–When they need it?
–At in-network cost sharing?
• If the answer is No, time to get to work to
protect consumers
• Many forums for action
For more information
Health Access California
1127 11th Street, Suite 234, Sacramento, CA 95814
1330 Broadway, Suite 811, Oakland, CA 95612
1930 Wilshire Blvd., Suite 916, Los Angeles, CA 90057

similar documents