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Improving Network Adequacy and
Provider Directory Standards in
Georgia
Meredith Gonsahn, MPH
Health Policy Analyst
Februar...
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...
Current Network Adequacy Standards in Georgia
• Outdated and inadequate
• “Sufficient” and “reasonable” are open to
interp...
Policy Activity around Network Adequacy
• Federal standards and
the NAIC Model Act
• SB 158
• The Consumer and
Provider Pr...
Policy Recommendations for Network Adequacy
• Multi-stakeholder process
focused on consumer
priorities
• Adopt NAIC Model ...
First things first!
Transparency: An Important First Step
• Provider directories are an important tool for
consumers
• Directories are frequen...
SB 302: Provider Directory Improvement Act
Accuracy provisions include requirements for:
• Regular updating of directories...
SB 302: Provider Directory Improvement Act (Cont.)
Usability provisions include requirements for:
• Plain language informa...
Resources
• SB 158 Consumer and Provider Protection Act
• Consumer and Provider Protection Act Study
Committee Report
• SB...
Thank you!
:
100 Edgewood Avenue, Suite 1015
Atlanta, GA 30303
Phone: 404-567-5016
Fax: 404-935-9885
info@healthyfuturega....
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Getting What You Pay For - Consumer Protections for Network Adequacy and Provider Directories

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GHF health policy analyst, Meredith Gonsahn, presented on improving network adequacy and provider directory standards in Georgia.

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

  1. 1. Improving Network Adequacy and Provider Directory Standards in Georgia Meredith Gonsahn, MPH Health Policy Analyst February 2, 2016
  2. 2. Georgians for a Healthy Future
  3. 3. Objectives • Network Adequacy • Provider Directories • Resources
  4. 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. 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 Current Network Adequacy Standards in Georgia • Outdated and inadequate • “Sufficient” and “reasonable” are open to interpretation • Consumers have no guaranteed benchmark for services and enforceable rights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. 6. Policy Activity around Network Adequacy • Federal standards and the NAIC Model Act • SB 158 • The Consumer and Provider Protection Act Study Committee
  7. 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
  8. 8. First things first!
  9. 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. 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. 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. 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. 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

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