Making Health Plans Play Fair GARRY CARNEAL, JD SENIOR POLICY ADVISOR THE KENNEDY FORUM FEBRUARY 5, 2016

The Five Pillars

The Parity Challenge Understanding how health insurance functions Becoming familiar with your plan documents What does a parity violation look like? o Distinguishing between medical necessity and benefit determinations o Network adequacy o Steerage policies o Clinical criteria used in the decision-making process Demanding disclosure and transparency Engaging the attending provider Understanding appeals process, and then actually filing appeals Accessing parity experts (e.g., legal advocate)

Commercial Insurance  Commercial insurance  Group coverage above 50  Small group coverage  Individual/non-group coverage  Insurance types  Indemnity  HMO/PPO/POS  Blues  Workers’ comp  Specialty Insurance Types  Self-funded  Government plan Federal State Local  TriCare  Medicare  Medicaid  Dual eligible  Taft Hartley Regulatory Frameworks

Understanding the Appeals Process 5 UM Appeal Timing Expedited vs. Standard Type: Prospective, Concurrent, Retrospective Administrative/Grievance Procedure Appeal Parity Appeal Internal Appeals External Review Appeal Regulator Complaints Accreditation Audits Arbitration Hearing Judicial Hearing External Appeals

Understanding Parity Violations Understanding the anatomy of a parity violation Identifying and tracking complaints Health plan risk management programs Developing standardized auditing criteria Federal and state auditing -- examples o New York o California o Maryland  Legal actions o Class action lawsuits o Agency fines

Moving Towards Parity Promoting state oversight Understanding corporate practice of medicine Moving towards evidence-based medicine and comparative effectiveness Accessing parity resources (e.g., the Parity Resource Guide) Developing additional plan policies and standards Actually filing appeals Utilizing legal remedies Improving audit methodology Creating communities to shring parity violation case examples

Resources

Contact Information Garry Carneal, JD Senior Policy Advisor The Kennedy Forum (202)