Timely Access & Network Adequacy The California Experience Health Access California January

Health Access California California’s statewide healthcare consumer advocacy coalition Created in late 1980s Fought for: – 1990s: HMO Reform, Patient Bill of Rights – Coverage Expansions: Medicaid, Employer, Comprehensive – State Budget Battles – The Affordable Care Act

California Market 38 Million Californians Medicare: 4.5 million Medicaid: million – Over 8 million in Medicaid Managed Care Department of Managed Health Care: million, including Medi-Cal managed care California Department of Insurance: under 2 million (no recent data) Remaining uninsured: million

California Context Two regulators Department of Managed Health Care – Created in 1999, Legislation sponsored by Health Access – Regulates PPOs, EPOs and HMOs – Regulates coverage for million Californians California Department of Insurance – Elected Insurance Commissioner since 1988 – Regulates health insurance, including PPOs and EPOs but not HMOs – Regulates coverage for 2 million Californians

Foundational Concept Managed Care, Limited Networks, ACOs work only if the consumer is guaranteed: The Care You Need When You Need It at In-Network Cost Sharing – Not the care you want when you feel like it. – Not the doctor you want but the care you need. What you need when you need it. At in- network cost.

Network Adequacy Primary Care, Hospital Care: – Geographic access: 15 miles, 30 minutes – Provider ratios: 1/1200. Updated to add NPs, PAs Specialty care: the specialist you need at in-network cost sharing. What the provider is paid is up to the plan and the provider, not the consumer. If medically necessary care not available in network, the health plan obliged to arrange it for consumer at in-network cost sharing. – Applies to all care but most relevant to highly specialized care or care where timeliness is critical 1995: Wilm’s tumor: $500,000 fine Heart surgery Transgender Care

Timely Access to Care In 1975, law said: ”All services shall be readily available at reasonable times to each enrollee consistent with good professional practice.” In 1997, Health Access sponsored AB497: – same-day urgent care – non-urgent care in ten days – answer the phone in four minutes In 2010, regulations impose time-elapsed standards: – 48 hours for urgent care – Telephone triage within 30 minutes – Non-urgent care: 10 days for primary care 15 for specialty

Balance Billing Surprise! Consumers Owe Money! Cost sharing for emergency care: – In-network cost sharing whether in-network or out of network emergency care for PPOs/HMOs/EPOs regulated by DMHC – For health insurers, consumers pay out of network cost sharing at out of network emergency rooms. Pending regulations: see 2015 efforts – Counts toward annual out of pocket limit for both DMHC and Ca Department of Insurance Surprise bills: hospital-based physicians! Big problem! See 2015 efforts

Out of Network Benefit Customary for PPO, No Statutory Standards Little Used: – Cost for consumers higher, much higher – Not count toward annual out of pocket limit – If adequate network with timely access, should be unnecessary to obtain needed care Does it let health insurers off the hook? – If a consumer is encouraged to go out of network at the consumer’s expense, does that let the HMO or PPO off the hook for an adequate network?

Provider Directory California’s experience to date: What a mess! Non-routine surveys of Anthem and Blue Shield in 2014: – Directories 2-3 years old – 25% or more of providers not correct! Medi-Cal managed care worse! Law designed for pre-Internet era and not as good as the Yellow Pages

Recent Efforts 2014: SB964 – Annual reporting on network adequacy – Annual reporting on timely access – All products regulated by DMHC: group, individual, Medicaid, Exchange – Separate reports for separate networks Many commercial plans use different networks for Medicaid than for commercial Some use different networks for individual market than for employer market 2014: Covered California – Big problems with narrow networks, inaccurate provider directories: – On narrow networks, we advocated, they acted. – On provider directories, need legislation

2015 Efforts Provider Directory: – Standardize format across plans/insurers – Allow people to shop for Medicaid managed care, exchange, off-exchange, group coverage Surprise bills at in-network facilities: – Consumer pays in-network cost sharing unless voluntarily consents to out of network provider Timely Access monitoring California Department of Insurance emergency regulations

Challenges Enforcement – Complaints not enough – Good standards meaningless unless regulator has survey capacity Business interests of plans and providers different than consumers – sometimes plans/providers interest harmonize to detriment of consumers: timely access ACA: brings into focus addl gaps/problems (provider directory, standard formularies) Inherent tension between limited networks and access Rural areas: California: large geography, small % of population

Advocacy Lesson When in doubt, ask yourself: – Are Consumers Getting the Care They Need? – When they need it? – At in-network cost sharing? If the answer is No, time to get to work to protect consumers Many forums for action

For more information Website: Blog: Facebook: Twitter: Health Access California th Street, Suite 234, Sacramento, CA Broadway, Suite 811, Oakland, CA Wilshire Blvd., Suite 916, Los Angeles, CA