Exchange Provider Network Standards
Ensuring that coverage translates into access to care requires attention to the adequacy of provider networks. States will need to ensure that standards meet federal requirements, and may want to tailor standards to meet state specific needs.
*Milestone details:
*Full name: Adopt provider network standards for plans in the Exchange that meet or exceed those required by federal laws and regulations.
*Relevance to the ACA:
The ACA establishes minimum criteria for qualified health plans sold on an Exchange; these criteria include provider network standards. Relevant sections include:
§1311 - Qualified health plans must meet these minimum provider network standards:
-- ensure a sufficient choice of providers.
-- comply with rules limiting the re-entry of an insurer in geographic areas in which that insurer has previously denied coverage to new applicants because its provider network would be unable to adequately provide services.
-- provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers.
-- include within plan networks available non-profit and federally funded clinics and hospitals that serve low-income, medically-underserved individuals.
-- be accredited with respect to network adequacy and access by a recognized accreditation entity of health insurance issuers or plans, or receive such accreditation within a period established by an Exchange.
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New York
I was wondering if any states had established 'adequate' provider network standards as they relate to mental health/substance abuse providers. Including, but not limited to, types of providers, criteria they need to meet and so forth.
Was also curious if there has been use of 'provider quality data' for mental health/substance abuse providers?
Thank you in advance for any input or insights.
Alabama
The National Quality Forum has endorsed a set of quality measures for behavioral health that will likely serve as a baseline of measurement for behavioral health providers.
Missouri
Great question Linda!! As the leader in Network Adequacy standards, Quest Analytics has been working with many states on developing access standards similar to those used with CMS and Medicare Advantage. What I have found is that most states are using their Medicaid standards that haven't been updated for many years. Most of those states don't define the specialties but instead group all "specialists" together which could include MH/SUD but there's no way to know for sure. CMS does an excellent job of defining the specialties down that Seniors need to use (many could be used for the under 65 pop) and for Exchanges we feel that the states need to identify the specialists that will be important and define appropriate access standards around those specialties like MH/SUD. By defining the specialties, like MH/SUD, it helps prevent adverse selection by making sure that the "specialists" grouping contain the proper amounts and proper types of providers for all Health Plans. We do the measuring/verifying for CMS and we could do the exact same for any and All Exchanges. Many States are taking a closer looks at the Adequacy requirements and the specialties required and will soon publish those standards. If you would like to discuss more contact me at robert.smith@questanalytics.com. To obtain your complimentary Network Adequacy whitepaper, visit us at http://www.questanalytics.com/whitepaper.aspx
Missouri
My apologies Lubna, mis-typed your name.
District of Columbia
The NAIC Exchange subgroup recently adopted a white paper related to network adequacy and plan management, including issues for states selecting the partnership model.
District of Columbia
This document covers in depth questions relevant to Exchange planning and implementation, identifying where the ACA provides guidance, where further guidance is needed and factors that need to be considered when making decisions around the Exchange structure. Access the document here: http://www.statereforum.org/sites/default/files/exchange_questions_sep_2...
District of Columbia
This draft document provides responses to OCIIO provisions regarding the Exchange. It includes comments on Exchange operations, qualified health plans, actuarial value, enrollment, IT systems, and risk adjustment. Access the comments here: http://www.statereforum.org/sites/default/files/colorado.pdf
District of Columbia
This draft legislation establishes an Exchange under the authority of the Insurance Commissioner and outlines the functions and duties of the IA Exchange. Access the bill here:
http://www.statereforum.org/sites/default/files/iowa_sf_235-1.pdf
District of Columbia
This draft legislation would establish the Exchange under the office of the insurance commissioner and would require enrollees to purchase coverage through a broker. Access the bill here: http://www.statereforum.org/sites/default/files/iowa_sf391.pdf