Network Adequacy For Health Systems

P R O V I D I N G P O W E R F U L S O L U T I O N S
Will you be
Health Systems to
become a payer?

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I © 2014
Today’s Agenda
 Is becoming a payer worth the risk?
 What does Network Adequacy mean?
 What is my marketable service area?
 What is the financial opportunity with Medicare Advantage?
 Do I have the right mix and enough providers?
 Where is my network lacking?
 How do I fill deficiencies?

Here to Guide theWay
What’s your Quest?
Darren Huff, East Region Sales
Darren.Huff@QuestAnalytics.com
Contact us at:
920.739.4552

Worth the Risk?
1 in 5 Health Systems to Become Payers by 2018
A growing number of health systems are deciding that it is worth the risk. In a June
survey of more than 100 hospitals and health system across the country, 34 percent
responded that they already own health plans. Another 21 percent said they plan to
launch a health insurance plan by 2018, according to the Advisory Board.
http://www.healthleadersmedia.com/page-1/HEP-295415/1-in-5-Health-Systems-to-Become-Payers-by-2018
That equates to 55% of today’s health systems
will be Payers by 2018

When is Network Adequacy Required?
 DOI
 Commercial Insurance Market
 Medicaid Programs
 Medicare Programs
 FFM & SBM

What is Network Adequacy?

“It’s like you wouldn’t want to buy a car without
an adequate engine. You don’t want to buy an
insurance plan that doesn’t have an adequate
network, because when you actually go to use
that product, it’s not going to work.”
— Claire McAndrew, private insurance program director at Families USA, told AIS’s Health Reform Week.

Insurance Departments

Commercial Market

Medicaid Requirements
PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I © 201.4

Minimum number of providers
• Must contract with sufficient numbers of each
provider specialty type
• Must contract with sufficient number of each
HSD facility type
Maximum Travel Time & Distance to
Providers/Facilities
•90% of beneficiaries have access to at least one
provider/facility
•Contracted providers are not limited to the
boundaries of the county or counties as long as the
provider is within the time & distance requirement
CMS ADEQUACY

2015 PROVIDERT/D Requirements
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
Time
(minutes)
Distance
(miles)
001 General Practice
002 Family Practice
003 Internal Medicine
004 Geriatrics
005 Primary Care - Physician
006 Primary Care - Nurse
S03 Primary Care 10 5 15 10 30 20 40 30 70 60
007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110
008 Cardiology 20 10 30 20 50 35 75 60 95 85
010 Chiropractor 30 15 45 30 80 60 90 75 125 110
011 Dermatology 20 10 45 30 60 45 75 60 110 100
012 Endocrinology 30 15 60 40 100 75 110 90 145 130
013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110
014 Gastroenterology 20 10 45 30 60 45 75 60 110 100
015 General Surgery 20 10 30 20 50 35 75 60 95 85
016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110
017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130
018 Nephrology 30 15 45 30 80 60 90 75 125 110
019 Neurology 20 10 45 30 60 45 75 60 110 100
020 Neurosurgery 30 15 60 40 100 75 110 90 145 130
021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100
022 Oncology - Radiation/Radiation Oncology30 15 60 40 100 75 110 90 145 130
023 Ophthalmology 20 10 30 20 50 35 75 60 95 85
025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85
026 Physiatry, Rehabilitative Medicine 30 15 45 30 80 60 90 75 125 110
027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130
028 Podiatry 20 10 45 30 60 45 75 60 110 100
029 Psychiatry 20 10 45 30 60 45 75 60 110 100
030 Pulmonology 20 10 45 30 60 45 75 60 110 100
031 Rheumatology 30 15 60 40 100 75 110 90 145 130
033 Urology 20 10 45 30 60 45 75 60 110 100
034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130
035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130
2015 Provider Time and Distance Requirements
Metro Micro Rural
Specialty
Geographic Type
CEACLarge MetroCMS
Code

2015 FACILITYT/D Requirements
Number/
1,000
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Maximum
Time
(minutes)
Maximum
Distance
(miles)
Maximum
Time
(minutes)
Maximum
Distance
(miles)
040 Acute Inpatient Hospitals 12.2 20 10 45 30 80 60 75 60 110 100
041 Cardiac Surgery Program NA 30 15 60 40 160 120 145 120 155 140
042 Cardiac Catheterization Services NA 30 15 60 40 160 120 145 120 155 140
043 Critical Care Services – Intensive Care Units (ICU)NA 20 10 45 30 160 120 145 120 155 140
044 Outpatient Dialysis NA 20 10 45 30 65 50 55 50 100 90
045 Surgical Services (Outpatient or ASC) NA 20 10 45 30 80 60 75 60 110 100
046 Skilled Nursing Facilities NA 20 10 45 30 80 60 75 60 95 85
047 Diagnostic Radiology NA 20 10 45 30 80 60 75 60 110 100
048 Mammography NA 20 10 45 30 80 60 75 60 110 100
049 Physical Therapy NA 20 10 45 30 80 60 75 60 110 100
050 Occupational Therapy NA 20 10 45 30 80 60 75 60 110 100
051 Speech Therapy NA 20 10 45 30 80 60 75 60 110 100
052 Inpatient Psychiatric Facility Services NA 30 15 70 45 100 75 90 75 155 140
054 Orthotics and Prosthetics NA 30 15 45 30 160 120 145 120 155 140
055 Home Health NA
056 Durable Medical Equipment NA
057 Outpatient Infusion/Chemotherapy NA 20 10 45 30 80 60 75 60 110 100
061 Heart Transplant Program NA
062 Heart/Lung Transplant NA
064 Kidney Transplant Program NA
065 Liver Transplant Program NA
066 Lung Transplant Program NA
067 Pancreas Transplant Program NA
2015 Facility Time and Distance Requirements
Specialty
Micro Rural CEACMetro
CMS
Code
Large Metro
Geographic Type

FFM & SBM
….Unlike the certification process for benefit year 2014, CMS will no longer simply utilize issuer
accreditation status, identify states with review processes at least as stringent as those
identified in 45 C.F.R. 156.230(a), or collect network access plans as part of its evaluation of
plans’ network adequacy. Rather, CMS will assess provider networks using a “reasonable
access” standard, and will identify networks that fail to provide access without unreasonable
delay as required by 45 C.F.R. 156.230(a)(2). In order to determine whether an issuer meets the
“reasonable access” standard, CMS will focus most closely on those areas which have
historically raised network adequacy concerns.

SBM: Exchange Requirements
 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 insureds 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

How can I evaluate my current
provider network to know if I
meet Network Adequacy?

Where do I start?
PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014

What is my marketable service area?

Why isn’t DC a slam dunk?

Revenue Opportunity
HSD
Reference
File
Reimbursement
Rates

Revenue Opportunity

Do I have the right mix and enough providers?

Quest Analytics
PROVIDER IMPACT ANALYSIS
Additional Services

PROVIDER RANKING
Any single provider
at one of these
locations would
provide access to
90% of membership.
Very little
or no impact,
not worth
the effort.
Have an
impact, but
would not meet
by their single
location.
Results of a
provider
ranking
analysis report
based on a
recruitment
list.

MEASURING IMPACT

MEASURING IMPACT across counties

UTILIZATION/COST/QUALITY

BUILT withVISION
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.

QUEST ANALYTICS SUITE ™
 ACCESS ANALYSIS
 Access Analysis I Access Comparison I Mapping
 ADEQUACY ANALYSIS
 Medicare Advantage I Medicaid I Dual Eligibles I Exchanges I Commercial
 GEOCODER & DATA STANDARDIZATION
 Address-Level Accuracy I Data Standardization I Zip Correction
 DISRUPTION ANALYSIS
 Transparency & Confidence I Provider Change Analysis
 QUALITY NETWORK ANALYSIS
 Hospital Quality I Tiered Networks

Quest Analytics
THE QUEST CLIENT FAMILY
Absolute Total Care
AcariaHealth
Adena Health Plan
Advantica
Advicare
Aetna
AlwaysCare
American Republic
AmeriGroup
AmeriHealth Mercy
AmeriHealth NJ
Ameritas
Amida
Arcadian Health Plan
Archcare
Argus
Argus Dental
Arkansas BCBS
Assurant Health
Atrio Health Plan
Aultman
Avesis
AvMed
Bay Care Physicians
BeechStreet
Benecard PBM
BeneCare
Blue Cross Idaho
BCBS Arizona
BCBS Kansas City
BCBS Michigan
BCBS Nebraska
BCBS North Carolina
BCBS Tennessee
Bluegrass
BlueShield CA
Mount Carmel
MVP Health Care
Navitus
Neighborhood Rhode Island
Network Health MA
Network Health Plan of Wisconsin
Nevada COOP
New Mexico Health Connection
NorthShore –LIJ Health System
NovaSys Health
OnPoint
OptiCare Managed Vision
PacificSource
Palladian
Parkview Health Plan
PatientChoice
Peach State Health Plan
Physicians Health
Physicians United Plan
Piedmont Community
Premier Access
Premier Eye Care
Premiere Health
Prime Therapeutics
PrimeWest
Principal
Priority Health
Regence/Cambia
ReStat
Revolv
Sanford Health
SCAN
Scion Dental
Elderplan
ElderServe
Encore
Evolent
Fallon Community
FamilyCare-OR
Family Health Network
Fidelis
Florida Combined Life
Florida Health Care Plus
Freedom Health
Gateway
Geisinger
GemCare
Glenridge Healthcare
Gorman
Granite State Health Plan
Group Health Coop
Guardian
Harvard Pilgrim
HFN
HHH
HSAG
HealthNet
HealthNow
HealthPartners MN
Health Partners PA
Health Plan of MI
Health Smart
HealthSpan
Health Spring
Health Velocity
Heritage Health

Quest Analytics
Health Systems
Aultman
BayCare Health System
Catholic Health Initiatives
Geisinger Health System
Memorial Hermann Healthcare System
Mount Carmel
North Shore-LIJ Health System, Inc
Parkview Health
Sanford Health
Trinity Health & Catholic Health East
University of Arizona Health
Virginia Premier

Partnerships

Quest Analytics
VALUE PROPOSITION

Providing Network Adequacy SOLUTIONS
Competitive Edge
Network Adequacy Pass/Fail Results with MA Provider and Facility Tables
Market Opportunity Return on Expansion
Government Programs & Commercial
All in One Solution-Access/Adequacy/Disruption/Geocoder/Quality
Meeting Needs Across Departments-IT/Sales/Contracting/Member Services
A long-term solution
in place to meet current and future needs with automation and integration options
Desktop
API/Server
Cloud
An Industry Partner
Software updates, including year-over-year criteria changes
Innovation
(Optional)
Provider Impact Analysis Services

TRAINING & SUPPORT
 Onsite, Hands-on Training
 Regular Data Updates
 Feature Additions and/or
Enhancements
 LinkedIn Support Group
 What’s New Web Overviews
with New Releases
 Unlimited phone, email and
web-based support -
all US based.
 Annual User Conference

Q&A
What’s your Quest?
Darren Huff, East Region Sales
Darren.Huff@QuestAnalytics.com
Contact us at:
920.739.4552

QUALITY
UNDERSTANDING
EVOLVING
SUPPORT
TEAM
Network Adequacy Experts Providing POWERFUL I CONSISTENT I PROVEN Solutions

Network Adequacy For Health Systems

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