Tiered and Narrow Networks Matthew Katz EVP/CEO Connecticut State Medical Society OSMAP November 13, 2015

Tiered and Narrow Networks United Medicare Advantage Health Insurance Exchange State Legislation Federal Legislation

United Medicare Advantage Network Terminations announced from United MA network in 2013 FCMA action Amicus filed by AMA, CSMS, PAI and a number of state, county and national and state specialty societies

United Medicare Advantage Network Started in the Northeast and continued throughout the country CMS determined it wasn’t in violation of Medicare Advantage network adequacy standards Arbitration offered to physicians- few took advantage of it

Health Insurance Exchange Federal standard for states with federal exchanges Connecticut has very limited network adequacy provision for exchange plans All plans but HealthyCT (CT CO-OP) have tiered, narrowed or limited exchange networks

State Legislation Clearly identify provider networks - The provider network must be clearly identified, and consumers must be able to receive specialty and subspecialty care “in- network” Ensure adequate access to in-network care – Without adequate networks, consumers must look for care “out of network” Significant financial disincentives for obtaining appropriate preventive care, medical care Lacking access to in-network highly specialized care can drive the sickest patients out of network – potentially benefitting the insurer’s profit margin Use objective data to confirm network adequacy Include numbers of primary care, specialty care physicians relative to other healthcare providers in the network. Make the information available to consumers and physicians, as well as regulators Ensure that enrollees can receive all covered services in a timely and geographically accessible basis at the preferred in-network rate.

Connecticut Senate Bill 811 Legislation passed to encourage tiered or narrow networks as a way to reduce premium expense Patient pays but pays later so it appears that premiums are reduced or not going up at such a high rate

Federal Regulation/Legislation GAO report finding CMS significantly deficient in their monitoring of Medicare Advantage network adequacy 3% of plans per year reviewed for network adequacy and related network and directly accuracy

US Representative Rosa DeLauro (CT) Patient MA Bill of Rights To enhance beneficiary and provider protections and improve transparency in the Medicare Advantage market, and for other purposes Provider directory transparency and network adequacy standards proposed