Families USA Health Action Workshop Provider Access: Network Adequacy and Balance Billing January 22, 2015 Amanda Peden, MPH Health Policy Associate, Community Service Society of NY and Health Care For All New York Coalition

What’s the issue? 2 “Surprise” medical bills #1 complaint for state insurance regulators/AG office Lead to medical debt ‒ #1 complaint for Consumer Financial Protections Bureau ‒ 43 million Americans unpaid medical debt on credit cards ‒ Leading cause of personal bankruptcy

The problem Big, unexpected bills –Surprise bills even though consumer does everything right –Excessive bills for Emergency room Inadequate & outdated provider networks Inadequate disclosure and price transparency OON coverage can be illusory (low reimbursement) It was all legal! ‒ Consumers had no bargaining power or rights (except for HMO) ‒ No authority for well-intentioned regulators to act 3

Fixing the problem: a brief timeline 4 Late 90s April 2015 HMOs have protections, but nobody else… DFS releases report: An Unwelcome Surprise HCFANY begins advocating for surprise bills protections Surprise bills legislation fails in Assembly Surprise bills legislation PASSES! New law takes effect

How does the law address the problem? 5 1.Holds consumers harmless ‒ Pay in-network cost sharing for surprise bills at participating hospitals, ambulatory surgery sites, and when referred for OON services ‒ ER care (carriers pay, consumers only have to pay in-network cost sharing) 2.Establishes an independent review process for OON bills ‒ Bills resolved between carrier v. provider or uninsured v. provider ‒ “Baseball” arbitration (forces reasonableness) 3.Improves disclosure by insurance plans and providers ‒ Hospitals: standard charges, which insurance it takes and if MDs are “par” ‒ Providers: carriers, how much consumer might pay (upon request) ‒ Carriers: reimbursement methodology and how it compares to UCR 4.Extended network adequacy protections to more types of insurance plans; provides care through OON provider when no in-network provider; expands external appeal rights to these situations

5 strategies for winning OON protections 6 1.Show the problem 2.Educate the legislature 3.Leverage your allies 4.Engage the media 5.Make sure you get the right solution

(1) Show the problem 7 Identify and quantify the problem ‒ DFS report issued in 2012 ‒ Community Health Advocates (consumer assistance) OON billing cases Have compelling client stories −Get a “super” or activist consumer to lobby with you −Prepare them to be in the media Consumer!

(2) Educate the legislature 8 Ask the Legislature to hold a hearing −Or hold one yourself!

(3) Leverage your allies 9 Leverage your usual allies −Work with Coalition partners −Work with other coalitions −Work with like-minded consumer groups Collaborate with “non traditional” allies −Health plans −Provider trade groups

(4) Engage the media 10 Hold press conferences −With key partners, consumers, and state regulators if you are working together Media buys −Consider placing ads on political blogs or low-cost papers in low- rent districts

(5) Make sure you get the right solution 11 Discuss with colleagues Do research on other state laws Stick around for implementation −Make sure regulations and guidance reflect consumer concerns −Consumer education and outreach −NY Law provides for “out-of-network reimbursement rate workgroup” to look at OON coverage, reimbursement rates