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Making ACA Coverage a Reality – A National Examination of Provider Network Monitoring Practices by States and Health Plans
Funded by the Robert Wood Johnson Foundation
June 13, 2015
HMA
Background
• Anecdotal evidence suggests that access to providers has varied considerably across state Medicaid programs’ contracted Medicaid MCOs (MMCO)
• Raises concerns among policymakers, advocates, and other stakeholders about the degree to which access to providers is adequate in:– MMCO networks for the Medicaid expansion
population– Qualified Health Plan (QHP) networks
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Project goals
• Position states and health plans to ensure meaningful coverage for the most vulnerable people in response to the ACA and growth of enrollment in public programs
• Identify greatest challenges and best practices for achieving reliable network access
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Deliverables
• Report of network measurement and monitoring practices, challenges and solutions by states and health plans for Medicaid managed care and Marketplace programs
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Project methodology
• Develop survey tools (4 versions)• Field online survey to 4 target groups:
– Medicaid agencies (39 states + D.C.)– MMCOs (30)– Dept. of Insurance/Marketplace agencies
(43 states + D.C.)– QHP carriers (30)
• Telephone interviews with subset of each group (3 per target group)
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Target group considerations
• Medicaid agencies with managed care contracts
• Dept. of Insurance with provider network monitoring responsibilities
• Geographic representation• State alignment across the 4 target groups• Mix of health plan types by enrollment,
age, pure play/multi-line commercial/ publicly traded/community-affiliated
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CMS Regional Map
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MEDICAID AGENCY DEPT. OF INSURANCE QUALIFIED HEALTH PLAN MEDICAID MCO AZ AZ AZ AZCA CA CA CACO CO CO CODC DC DC DCFL FL FL FLGA GA GA GAHI HI HI HIIA IA IA IAIL IL IL ILIN IN IN INKS KS KS KSKY KY KY KYMA MA MA MAMI MI MI MIMN MN MN MNMO MO MO MOMS MS MS MSNE NE NE NENM NM NM NMNY NY NY NYOH OH OH OHPA PA PA PARI RI RI RISC SC SC SCTN TN TN TNTX TX TX TXUT UT UT UTVA VA VA VAWA WA WA WAWI WI WI WIDE ARLA CT
ND DENH LANJ MTNV NDOR NHSD NJWV NV
ORSDWV
MEDICAID: 39 DOI: 43 QHP: 30 MMCO: 30
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Survey tool contents
• Section 1 – Thresholds for access standards• Section 2 – Monitoring practices• Section 3 – Background information
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Survey length
SURVEY VERSION NUMBER OF QUESTIONS
Medicaid agency 48
MMCO 45
Dept. of Insurance/Marketplace office 53
QHP 38
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Telephone interviews
• 3 respondents from each target group• To be selected from responses that
demonstrate well defined provider network monitoring measures, standards and practices with the potential to share innovative, solution-oriented changes and recommendations
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Survey tool contents - examples
• Section 1 – Thresholds for access standards• Section 2 – Monitoring practices• Section 3 – Background information
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Sample access threshold questions – slide 1
Does your state agency require MCOs/QHPs to (does your MCO/QHP) cover care provided by non-network providers
when that care is provided at an in-network facility?
Does your state agency require MCOs/QHPs to (does your MCO/QHP) cover the services of
new members in active treatment with an OON provider for a minimum period of time in order to maintain continuity
of care in the member’s treatment?
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Sample access threshold questions – slide 2
Does your state agency (MCO/QHP) require that a minimum percentage of PCPs in an MCO’s/QHP’s network accept new patients?
…has the Medicaid managed care program considered encouraging Medicaid MCOs that operate QHPs to:
• Replicate the QHP’s ECP networks in the Medicaid MCO provider network?
• Have significant overlap in the contracted Medicaid MCO and QHP provider networks?
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Sample access threshold questions – slide 3
CYSHCN provider access questions
for MACPAC/Urban Institute study
Limited to Medicaid agency and
Medicaid managed care organization
surveys
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Survey tool contents - examples
• Section 1 – Thresholds for access standards• Section 2 – Monitoring practices• Section 3 – Background information
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Sample monitoring questions – slide 1
Please indicate which of the following ways your state agency monitors MCO/QHP provider networks:• Review of entire or sample of provider network file
submission• Conduct or require that MMCO/QHP conduct spot
checks to confirm network provider status• Rely on accreditation process by independent entities • Coordinate network monitoring between Medicaid
agency and Dept. of Insurance
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Sample monitoring questions – slide 2
Please indicate the metrics that your state
agency/MMCO/QHP uses to identify potential network
deficiencies:
• % of OON encounters to total encounters
• Emergency room utilization rates• CAHPS survey results• Call center reports• Complaints and grievances
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Sample monitoring questions – slide 3
Please rate the challenges in updating/monitoring provider network info by significance of the challenge:• Obtaining complete, accurate and timely info on network
participation from providers/from plans• Having adequate # of qualified staff to perform network analysis• Lacking IT infrastructure to automate or facilitate monitoring• Educating consumers regarding the use of network providers
(states)• Reconciling updates to credentialing records, provider directories
and provider contracts (plans)
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Sample monitoring questions – slide 4
What additional strategies has your MMCO/QHP used
to improve its ability to meet the
state’s provider network standards?
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Project challenges
• Volatile topic – a hot potato with perceived risk and limited benefit
• Media reports on this topic are largely one-sided
• Lengthy survey• Survey requires input from multiple SMEs• Version control• Survey Monkey limitations• Topic is timely, project timeline is condensed –
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Preliminary response rate
# Medicaid Agencies
MMCOs Depts of Insurance/
Marketplaceoffices
QHPs
Sent 39 30 43 30Responded 14* 6 12** 5
% 36% 20% 28% 17%
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* Expecting responses from 3 more Medicaid agencies, totaling 17 or 44% response rate. **Two respondents indicated that their Marketplace office does not regulate network adequacy.
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Early observations – slide 1
Standard: PCP hospital admitting privileges?• The majority of plans still require PCPs to have
hospital admitting privileges; however the majority of state agencies do not require this.
Standard: Cover non-network provider care at in-network facilities?• While the majority of state agencies that
responded do not require health plans to cover care provided by non-network providers when that care is provided at an in-network facility, the majority of health plans report that they do provide coverage in this instance.
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Early observations – slide 2
Standard: Continuity of care• Most Medicaid agencies and just under half of
DOI respondents require health plans to cover the services of new members in active treatment with an out of network provider for a minimum period of time in order to maintain continuity of care in the member’s treatment. (Some DOI respondents did not know the answer to this question.)
• All health plan respondents allow for out of network access to provide continuity of care.
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Early observations – slide 3
Standard: % of PCPs accepting new patients
• While a small portion of Medicaid agencies require that a minimum percentage of PCPs in an MCO’s network accept new patients, no DOIs require this.
• Some Medicaid MCOs and most QHP respondents require this of their PCPs.
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Early observations – slide 4
Standard: Alignment of MMCO/QHP networks
• All Medicaid MCO respondents offer a QHP and have taken steps to align their MMCO network with that of their QHP.
• Just one Medicaid agency and DOI respondent encourage this.
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QHP comment re: Essential Community Providers
“The Annual list the CMS publishes of ECP is difficult to work with. It has incorrect or invalid information that always needs to be manually
reviewed before being worked. Also CMS grouping of providers is different than the plan so there is more manual review to correlate the list.”
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Early observations – slide 5
Standard: Coverage when treated by OON providers listed in directory• State agency respondents are split on
whether to require health plans to cover eligible services rendered to members who see OON providers erroneously listed in the latest provider directory
• Most of the health plan respondents cover these services.
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Early observations – slide 6
Monitoring: • Medicaid agency respondents use multiple
methods to monitor provider networks, and most use several metrics to identify network deficiencies.
• DOI respondents primarily rely on one method (review entire provider network file) to monitor provider networks, and rely on accreditation processes as well. A small portion use metrics to identify network deficiencies.
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Karen Brodsky, Principal InvestigatorHealth Management Associates