Making Plans Meet the Need Networks: Narrow or

Anna Odegaard
Health Policy Analyst
SEIU Healthcare Minnesota
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
Why Narrower Networks Now?
 Exchanges promoting
competition on price
 Fewer ways for carriers to
distinguish products
 Overall trend toward
payment and delivery
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.
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
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
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)
ACA Requirements
What is
1. Geographic Access
2. Timely Access
3. Choice of Providers
4. Continuity of Care
Vehicles for Advocacy
1. Health Insurance Exchange Advisory Task Force
2. Legislative Process
3. MNsure Board and
Advisory Committees
Identifying Allies
Healthcare Providers
Patient Advocacy Orgs.
 MN Hospital Association
 MN Cancer Society
 MN Medical Association
 MN Heart Assoc.
 Community Health Centers
Advocacy organizations
 TakeAction Minnesota
 Legal Aid
 Minnesota Budget Project
 LGBTQ Health Roundtable
Labor Organizations
Small Business Organizations
Elected Officials
State Agency Staff
Articulating Goals
1. Draw on existing network
 HMOs
 Public Healthcare
 Other states
2. Look at comments on CMS
proposed regulations.
3. Talk to agency staff who
enforce existing standards.
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 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
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 innetwork 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 Standards
 Timely Access Standards (but not Appointment Wait Times)
 No Continuity of Care or Remedy language
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
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 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.
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?
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?
Anna Odegaard
[email protected]

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