Getting What You Pay For - Consumer Protections for Network Adequacy and Provider Directories

Georgians for a Healthy Future
Georgians for a Healthy FutureGeorgians for a Healthy Future
Improving Network Adequacy and
Provider Directory Standards in
Georgia
Meredith Gonsahn, MPH
Health Policy Analyst
February 2, 2016
Georgians for a Healthy Future
Objectives
• Network Adequacy
• Provider Directories
• Resources
Network Adequacy
• The ability of a health plan to provide
meaningful access to all covered benefits
• An old issue with a new urgency
• Why is this important to consumers?
Current Network Adequacy Standards in Georgia
• Outdated and inadequate
• “Sufficient” and “reasonable” are open to
interpretation
• Consumers have no guaranteed benchmark for
services and enforceable rights
Policy Activity around Network Adequacy
• Federal standards and
the NAIC Model Act
• SB 158
• The Consumer and
Provider Protection Act
Study Committee
Policy Recommendations for Network Adequacy
• Multi-stakeholder process
focused on consumer
priorities
• Adopt NAIC Model Act with
Georgia-specific
modifications
• Department of Insurance
enforcement
Quantitative Standards
• Provider-to-enrollee ratios
• Time distance standards
• Maximum appointment wait
times
• Right to go out of network
• Culturally competent care
• Essential community
providers
First things first!
Transparency: An Important First Step
• Provider directories are an important tool for
consumers
• Directories are frequently inaccurate and
consumers have very little protections
• Georgia’s current standards are not robust
• SB 302
SB 302: Provider Directory Improvement Act
Accuracy provisions include requirements for:
• Regular updating of directories every 30 days
• Available in electronic (and in print upon request) to all
• A dedicated email address, telephone number, and electronic link
that consumers can use to report inaccuracies
• Annual audits of all provider directories with a protocol in place for
health plans to follow up with providers
• Health plans to contact providers participating in networks who
have not submitted claims within 12 months to determine their
network participation status
• Honoring provider directory information if it is inaccurate and a
consumer ends up out-of-network based on that information
• Health plans to report periodically to the Department of Insurance
SB 302: Provider Directory Improvement Act (Cont.)
Usability provisions include requirements for:
• Plain language information about what provider directory
applies to which plan and the criteria used by plans to build
the provider network and to tier providers
• All pertinent information about participating providers and
facilities
• Search functionality that allows consumers to search by
health care professional, whether a provider is accepting
new patients, participating office locations, participating
hospitals, and other key pieces of information
• Accommodations for the needs of individuals with
disabilities and people with limited English proficiency
Resources
• SB 158 Consumer and Provider Protection Act
• Consumer and Provider Protection Act Study
Committee Report
• SB 302
• Visit healthyfuturega.org for issue briefs:
– Ensuring Access to Care: Setting and Enforcing
Network Adequacy Standards in Georgia
– Improving Provider Directory Accuracy and
Usability
Thank you!
:
100 Edgewood Avenue, Suite 1015
Atlanta, GA 30303
Phone: 404-567-5016
Fax: 404-935-9885
info@healthyfuturega.org
healthyfuturega.org
FOLLOW & SHARE
Meredith Gonsahn, MPH
mgonsahn@healthyfuturega.org
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Getting What You Pay For - Consumer Protections for Network Adequacy and Provider Directories

  • 1. Improving Network Adequacy and Provider Directory Standards in Georgia Meredith Gonsahn, MPH Health Policy Analyst February 2, 2016
  • 2. Georgians for a Healthy Future
  • 3. Objectives • Network Adequacy • Provider Directories • Resources
  • 4. Network Adequacy • The ability of a health plan to provide meaningful access to all covered benefits • An old issue with a new urgency • Why is this important to consumers?
  • 5. Current Network Adequacy Standards in Georgia • Outdated and inadequate • “Sufficient” and “reasonable” are open to interpretation • Consumers have no guaranteed benchmark for services and enforceable rights
  • 6. Policy Activity around Network Adequacy • Federal standards and the NAIC Model Act • SB 158 • The Consumer and Provider Protection Act Study Committee
  • 7. Policy Recommendations for Network Adequacy • Multi-stakeholder process focused on consumer priorities • Adopt NAIC Model Act with Georgia-specific modifications • Department of Insurance enforcement Quantitative Standards • Provider-to-enrollee ratios • Time distance standards • Maximum appointment wait times • Right to go out of network • Culturally competent care • Essential community providers
  • 9. Transparency: An Important First Step • Provider directories are an important tool for consumers • Directories are frequently inaccurate and consumers have very little protections • Georgia’s current standards are not robust • SB 302
  • 10. SB 302: Provider Directory Improvement Act Accuracy provisions include requirements for: • Regular updating of directories every 30 days • Available in electronic (and in print upon request) to all • A dedicated email address, telephone number, and electronic link that consumers can use to report inaccuracies • Annual audits of all provider directories with a protocol in place for health plans to follow up with providers • Health plans to contact providers participating in networks who have not submitted claims within 12 months to determine their network participation status • Honoring provider directory information if it is inaccurate and a consumer ends up out-of-network based on that information • Health plans to report periodically to the Department of Insurance
  • 11. SB 302: Provider Directory Improvement Act (Cont.) Usability provisions include requirements for: • Plain language information about what provider directory applies to which plan and the criteria used by plans to build the provider network and to tier providers • All pertinent information about participating providers and facilities • Search functionality that allows consumers to search by health care professional, whether a provider is accepting new patients, participating office locations, participating hospitals, and other key pieces of information • Accommodations for the needs of individuals with disabilities and people with limited English proficiency
  • 12. Resources • SB 158 Consumer and Provider Protection Act • Consumer and Provider Protection Act Study Committee Report • SB 302 • Visit healthyfuturega.org for issue briefs: – Ensuring Access to Care: Setting and Enforcing Network Adequacy Standards in Georgia – Improving Provider Directory Accuracy and Usability
  • 13. Thank you! : 100 Edgewood Avenue, Suite 1015 Atlanta, GA 30303 Phone: 404-567-5016 Fax: 404-935-9885 info@healthyfuturega.org healthyfuturega.org FOLLOW & SHARE Meredith Gonsahn, MPH mgonsahn@healthyfuturega.org