1. 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

2. 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

3. 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bills –Surprise bills even though consumer does everything right –Excessive bills for Emergency room Inadequate & outdated provider networks Inadequate disclosure and price transparency OON coverage can be illusory (low reimbursement) It was all legal!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

4. Fixing the problem: a brief timeline 4 Late 90s April 2015 HMOs have protections, but nobody else… DFS releases report: An Unwelcome Surprise 2012 2008 HCFANY begins advocating for surprise bills protections 2013 2014 Surprise bills legislation fails in Assembly Surprise bills legislation PASSES! New law takes effect

5. 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

6. 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

7. (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!

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

9. (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

10. (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

11. (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