Getting Pumped for State Healthcare Programs - Medicaid and Exhanges

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014
Getting Pumped for State Programs:
Medicaid/Exchange

TODAY’S QUEST PANEL
Darren Huff
Regional Sales Director – East Region
Darren.Huff@QuestAnalytics.com
Linda Borths
Director of Sales
Linda.Borths@QuestAnalytics.com
John Weis
President & Co-Founder
John.Weis@QuestAnalytics.com
Robert Smith
Regional Sales Director – West Region
Robert.Smith@QuestAnalytics.com

BUILT with VISION
QUEST ANALYTICS SUITE™
The industry's only software solution that has
continued to evolve to meet the changing demands of
Network Adequacy. The Quest Analytics Suite fully
integrates; Access, Disruption, Network Adequacy
(Medicare and Custom), Address-level Geocoding and
Hospital Quality Analysis into one easy to use suite.
ACCESS ANALYSIS
Access Analysis  Access Comparison 
Mapping
ADEQUACY ANALYSIS
Medicare Advantage  Medicaid 
Dual Eligibles  Exchanges 
Commercial RFP’s
GEOCODER & DATA
STANDARDIZATION
Address-Level Accuracy  Data
Standardization  Zip Correction 
True County Assignment
DISRUPTION ANALYSIS
Transparency & Confidence 
Provider Change Analysis
QUALITY ANALYSIS
Hospital Quality  Tiered Networks

National Marketplace Presence

It’s Not If…It’s When!

Access VS. Adequacy
CMS Revamps the process to:
1. Address geographic disparities across any state
2. Prevent adverse selection
3. Provide transparency of requirements
4. Apply consistency across plans
5. Leverage across programs


Network Adequacy for Medicaid

FLORIDA Medicaid Requirements

Medicaid Requirements
This is where
it turns Access
to Adequacy!

MedicaidTemplates
No Data
Does Not Meet the
Access Requirements

MedicaidTemplates
Pick your
Service Area
Pick Your
Provider Group
Once Publicized, the Templates
will be available to license here!
Print/Export
Your Reports


Network Adequacy for State Based
Exchanges

State Partnership
+
We are proud to have earned the business of
the DMHC. The DMHC has integrated the
Quest Analytics Suite for automating their
process for Qualifying Health Plans for
various government programs.

Exchange Requirements {Nevada}
 Compliance with the distance standards will be achieved if 95 percent of the population of the geographic
service area or existing HMO membership is within the distance standards of the providers with whom
the Carrier contracts.
 The minimum distance standards for PPO insured’s will be achieved if 50 percent of the population of the
geographic service area or the Carrier’s enrolled membership is within the distance standards of the
providers with whom the Carrier contracts.
Specialty
Urban Rural Frontier
Ratio Time Distance Time Distance Time Distance
Adult PCP 2500 45 45 60 60 100 120
OBGYN 2500 45 45 60 60 100 120
Pediatrics 2500 45 45 60 60 100 120
Urgent Care 5000 45 45 60 60 100 120
Emergency Medicine 5000 30 30 60 60 75 90
Mental Health 30000 30 30 60 60 90 90
Substance Abuse 30000 30 30 60 60 90 90
Cardiology 7500 60 60 90 90 180 180
Dermatology 17500 60 60 90 90 180 180
Gastroenterology 25000 60 60 90 90 180 180
Hematology/Oncology 17500 60 60 90 90 180 180
Nephrology 10000 60 60 90 90 180 180
Ophthalmology 27500 60 60 90 90 180 180
Orthopedics 10000 60 60 90 90 180 180
Otolaryngolgoy 25000 60 60 90 90 180 180
Pulmonology 20000 60 60 90 90 180 180
Surgery 12500 60 60 90 90 180 180
Urology 25000 60 60 90 90 180 180
*Essential Community Hospitals 60 60 90 90 180 180

ExchangeTemplates

Medicaid & Exchange Templates

Essential Community Providers
Minnesota Statutes, section 62Q.19
requires all health plans to offer
contracts to state designated
essential community providers
within their service areas.


What if Network Adequacy
Standards are not met?

CMS Exception Request
LIST THE CONTRACTED PROVIDERS/FACILITIES THAT WILL ENSURE ACCESS (THEY MUST BE LISTED IN THE
HSD TABLE UNDER THE COUNTY THEY’RE PROVIDING SERVICES TO).
ALSO, LIST THE CLOSEST CONTRACTED PROVIDER/FACILITY OF THE SPECIALTY CODE TYPE.
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and telephone number):
DISTANCE FROM MEDICARE BENEFICIARIES IN THE COUNTY:
PROVIDER NPI:
SPECIALTY TYPE:
PROVIDER NPI:
SPECIALTY TYPE:

Maximum Distance
greatest travel
distance?

How far does someone have to travel to receive care?
Some States May Ask For
The Maximum
Distance/Time That a
Member Will Have to Travel
Outside the Requirements!


Network Adequacy for FFM

New Partnership

Data CollectionToday…with more to follow

Data CollectionToday…with more to follow
CCIIO Network Adequacy Data Template
National
Provider
Number
(NPI)*
First
Name of
Provider*
Last Name
of
Provider*
Physician
/ Non-
Physician*
Specialty
Type
(area of
medicine)*
Street
Address*
City* State* County* Zip* Network
IDs*

Competitive Positioning
Giving you an
apples-to-apples
comparison of
your data in One
Application!


Providers that Fit:
Narrow Networks Strategies and
Design

Thank you very much!
Darren Huff
Regional Sales Director – East Region
Darren.Huff@QuestAnalytics.com
Linda Borths
Director of Sales
Linda.Borths@QuestAnalytics.com
John Weis
President & Co-Founder
John.Weis@QuestAnalytics.com
Robert Smith
Regional Sales Director – West Region
Robert.Smith@QuestAnalytics.com

Getting Pumped for State Healthcare Programs - Medicaid and Exhanges

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