Appendix 5. Arkansas Insurance Department Network Adequacy Guidelines and Targets

Transcription

1 Appendix 5 Arkansas Insurance Department Netwrk Adequacy Guidelines and Targets ACHI is a nnpartisan, independent, health plicy center that serves as a catalyst t imprve the health f Arkansans West Capitl Avenue Suite 300, Victry Building Little Rck, Arkansas

2 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 Appendix 5 AID Netwrk Adequacy Guidelines and Targets 45 CFR requires that Qualified Health Plans (QHPs) maintain a netwrk that is sufficient in number and types f prviders, including prviders that specialize in mental health and substance abuse services, t assure that all services will be accessible withut unreasnable delay. AID has develped the fllwing netwrk adequacy targets and data submissin requirements t ensure adequacy f prvider netwrks in QHPs ffered in the Federally-Facilitated Marketplace (FFM, r Marketplace ). Failure t meet these standards may nt preclude participatin in the FFM in the first year f evaluatin, but may require additinal justificatin. AID will evaluate whether r nt the targets shuld be adpted as QHP standards in future years. Medical issuers wh apply fr participatin in the Marketplace may already be accredited and s may nt need t submit additinal netwrk access infrmatin as part f the applicatin prcess. Nn-accredited issuers and dental issuers will be required t submit netwrk infrmatin. Additinal detail n submissin requirements is utlined belw. All issuers, bth accredited and nn-accredited, will be required t cmply with the prvider directry and ECP guidelines. Nte that QHP service areas in Arkansas may change and netwrk adequacy requirements in this standard must apply t updated service areas. Accreditatin Issuers are required t receive accreditatin n netwrk plicies and prcedures frm a qualifying accreditatin entity (NCQA r URAQ) prir t secnd year f Marketplace participatin. Prf f accreditatin must be submitted with the QHP applicatin (SERFF binder). Accreditatin entities have indicated that they will cnsider state standards in evaluating netwrk adequacy. AID will cmmunicate the time and distance targets belw t URAC and NCQA t be used in the accreditatin prcess. If carriers currently assess netwrks with mre stringent internal netwrk requirements (i.e. PCP available within 15 minutes r 15 miles), then they shuld prceed with existing internal standards. Accredited issuers shuld reprt time and distance GeAcess Maps and metrics accrding t the standards belw as part f QHP submissin. Time and Distance Targets AID recmmends that issuers and accreditatin entities evaluate netwrks based n the fllwing targets. If an issuer is nt accredited, GeAccess maps and ther infrmatin demnstrating netwrk access based n these targets must be submitted. PCP target: 1 prvider within 30 miles r 30 minutes Specialty care target: 1 prvider within 60 miles r 60 minutes Mental Health, Behaviral Health, r Substance Abuse (MH/BH/SA): 1 prvider within 45 minutes r 45 miles Appendix 5 Netwrk Adequacy Guidelines and Targets Page 2 f 7

3 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 GeAccess Map Guidelines GeAccess Maps and cmpliance percentages must be submitted fr each f the categries belw. Accredited carriers will be required t submit GeAccses maps fr reprting purpses. Map data is nly required fr service areas that are included in the QHP applicatin. Requested maps can be submitted separately r cmbined and distinguished by clr r ther methd. Please nte exceptins fr dental carriers. Primary Care: GeAccess Maps must be submitted demnstrating a 30 mile r 30 minute cverage radius frm each general / family practitiner r internal medicine prvider, and each family practitiner/pediatrician. Maps shuld als shw prviders accepting new patients. Dental carriers are nt required t submit separate categries, but shuld include nly nn-specialists in this requirement. Specialty Care: GeAccess Maps must be submitted demnstrating a 60 mile r 60 minute cverage radius frm each categry f specialist (see list f categries belw). Maps shuld als shw prviders accepting new patients. Specialists shuld be categrized accrding t the list belw. (Dental carriers d nt need t categrize specialists.) Hspitals * Hme Health Agencies Cardilgists Onclgists Obstetricians Pulmnlgists Endcrinlgists Skilled Nursing Facilities Rheumatlgists Opthalmlgists Urlgists Psychiatric and State Licensed Clinical Psychlgist * Hspitals types shuld be categrized accrding t hspital licensure type in Arkansas. MH/BH/SA: GeAccess Maps must be submitted demnstrating a 45 mile r 45 minute cverage radius frm MH/BH/SA prviders fr each f the categries belw. Maps shuld als shw prviders accepting new patients. Psychiatric and State Licensed Clinical Psychlgist Other (submit dcument utlining prvider r facility types included) Essential Cmmunity Prviders: GeAccess Maps must be submitted demnstrating a 30 mile r 30 minute cverage radius frm ECPs fr each f the categries belw. The prvider types included in each f the categries align with federal guidelines fr ECP prviders, with the additin f schl-based prviders included in the Other ECP categry FQHC Ryan White Prvider Family Planning Prvider Indian Prvider Hspital Other ECP Appendix 5 Netwrk Adequacy Guidelines and Targets Page 3 f 7

4 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 Perfrmance Metric Guidelines fr Nn-Accredited Carriers Nn-accredited issuers will be required t submit metrics demnstrating perfrmance fr each f the standards abve fr each cunty in the service area and verall service area. Accredited issuers will be required t submit these metrics fr reprting purpses. These include: The number f members and percentage f ttal members within access t a PCP within 30 minutes/miles, a specialist within 60 minutes/miles, r a MH/BH/SA prvider within 45 minutes/miles. The average distance t first, secnd, and third clsest prvider fr each prvider type. These figures shuld be prvided verall (entire state) fr each categry as well as stratified by cunty fr each categry. Fr example, the percent f enrlled members that are within 30 minutes r 30 miles f a general/family practitiner will be submitted with percentages verall and fr each cunty. The average distance t the first, secnd, and third clsest prvider will be submitted verall and fr each cunty. Issuers wh d nt yet have enrllees in the State f Arkansas will be exempt frm this requirement and must attest t nt currently having enrllees in Arkansas. Netwrk Access Plicies and Prcedures fr Nn-Accredited Carriers Nn-accredited carriers shuld submit an access plan describing cmpany plicies and prcedures fr ensuring adequate and sufficient netwrk access. The access plan shuld include narrative descriptin that addresses each f the fllwing: (1) The Qualified Health Plan Issuer s netwrk is sufficient in numbers and types f prviders t assure that all services t cvered persns will be accessible withut unreasnable delay. In the case f emergency services, cvered persns shall have access twenty-fur (24) hurs per day, seven (7) days per week; (2) The Qualified Health Plan Issuer s prcedures fr making referrals within and utside its netwrk and ntifying enrllees and ptential enrllees regarding availability f netwrk and ut-f-netwrk prviders; (3) The Qualified Health Plan Issuer s prcess fr mnitring and assuring n an nging basis the sufficiency f the netwrk t meet the health care needs f ppulatins that enrll in its health benefit plans; (4) The Qualified Health Plan Issuer s effrts t address the needs f cvered persns with limited English prficiency and illiteracy, with diverse cultural and ethnic backgrunds, and with physical and mental disabilities; (5) The Qualified Health Plan Issuer s methds fr assessing the health care needs f cvered persns; (6) The Qualified Health Plan Issuer s methd f infrming cvered persns f the plan s services and features, including but nt limited t, the plan s grievance prcedures, prcess fr chsing and changing prviders, and prcedures fr prviding and apprving emergency and specialty care; (7) The Qualified Health Plan Issuer s methd fr assessing cnsumer satisfactin; Appendix 5 Netwrk Adequacy Guidelines and Targets Page 4 f 7

5 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 (8) The Qualified Health Plan Issuer s methd fr using assessments f enrllee cmplaints and satisfactin t imprve carrier perfrmance; (9) The Qualified Health Plan Issuer s system fr ensuring the crdinatin and cntinuity f care fr cvered persns referred t specialty prviders, fr cvered persns using ancillary services, including scial services and ther cmmunity resurces, and fr ensuring apprpriate discharge planning; (10) The Qualified Health Plan Issuer s prcess fr enabling cvered persns t change primary care prfessinals; (11) The Qualified Health Plan Issuer s prpsed plan fr prviding cntinuity f care in the event f cntract terminatin f the Qualified Health Plan Issuer and any f its participating prviders, r in the event f the Qualified Health Plan Issuer s inslvency r ther inability t cntinue peratins. This plan shall explain hw cvered persns will be ntified f the cntract terminatin, r the Qualified Health Plan Issuer s inslvency r ther cessatin f peratins, and transferred t ther prviders in a timely manner; (12) The Qualified Health Plan Issuer shall prvide access r cverage fr health care prviders as required by federal law; (13) The Qualified Health Plan Issuer s prcedures t ensure reasnable prximity f participating prviders t the business r persnal residence f cvered persns; (14) The Qualified Health Plan Issuer s plan that shws hw it will cntinually mnitr the ability, clinical capacity, financial capability and legal authrity f its prviders t furnish all cntracted benefits t cvered persns; (15) The Qualified Health Plan Issuer s prcedures that ensure that if the Issuer has an insufficient number r type f participating prviders t prvide a cvered benefit, the cvered persn btains the cvered benefit at n greater cst t the cvered persn than if the benefit were btained frm participating prviders; and (16) Qualified Health Plan Issuer shuld file with the Cmmissiner sample cntract frms prpsed fr use with its participating prviders and intermediaries In additin, the applicant shuld describe the prcess fr ensuring that if there is insufficient number r type f participating prviders fr an enrllee t access cvered benefits that there is at least ne participating prvider in the next clsest city r mileage and drive time radius. Standards fr Essential Cmmunity Prviders (ECPs) Issuers (accredited and nn-accredited) must cmplete and submit the Essential Cmmunity Prviders template and must include in the template all qualifying ECPs in the netwrk. Qualifying ECPs include prviders described in sectin 340B f the PHS Act and sectin 1927(c)(1)(D)(i)(IV) f the Scial Security Act. AID will review plans accrding t the ECP standards in the April 5, 2013 Letter t Issuers unless CCIIO releases additinal guidelines prir t the plan year 2015 certificatin perid. Each issuer will be required t meet cnditins f the Private Optin 1115 Waiver and ffer at least ne QHP that has at least ne FQHC r RHC in each service area f the plan netwrk. ECPs in the prvider netwrk shuld be submitted in the FFM ECP template and the ECP Categry belw shuld be indicated (as in plan year 2014 QHP Certificatin). Appendix 5 Netwrk Adequacy Guidelines and Targets Page 5 f 7

6 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 FFM Categrizatin f ECPs in ECP Data Submissin Template (with additin f schl-based prviders) ECP Categries FQHC Ryan White Prvider Family Planning Prvider Indian Prvider Hspital Other ECP Prvider ECP Prviders FQHC and FQHC lk-alike clinica, Native Hawaiian Health Centers Ryan White HIV/AIDS Prviders Title X Family Planning Clinics and Title X Lk-Alike Family Planning Clinics Tribal and Urban Indian Organizatin Prviders Disprprtinate Share Hspitals (DSH), Children s Hspitals, Rural Referral Centers, State Cmmunity Hspitals, Free-standing Cancer Centers, and Critical Access Hspitals Sexually Transmitted Disease (STD) Clinics, Tuberculsis (TB) Clinics, Hemphilia Treatment Centers, Black Lung Clinics, and Schl-Based Prviders Inclusin f Schl-Based Prviders Prviders wh are schl-based prviders and meet credentialing and certificatin standards f issuers will be included in the ECP template submissin, categrized as Other. Issuers shuld submit a separate list f schl-based prviders as part f the QHP applicatin. At a minimum, prviders shuld be identified by NPI, physician r clinic name, address, and prvider type. The 2013 Letter t Issuers als requires that issuers ffer cntracts prir t the cverage year t: All available Indian prviders in the service area, using the mdel QHP Addendum fr Indian prviders develped by CMS; and At least ne ECP in each ECP categry (see Table 2.1) in each cunty in the service area, where an ECP in that categry is available. The AR Marketplace will additinally require that issuers ffer a cntract t at least ne schl-based prvider in each cunty in the service area, where a schl-based prvider is identifiable and available and meets issuer certificatin and credentialing standards. Prvider Directries 45 CFR Sectin (b) states that a QHP issuer must make its prvider directry fr a QHP available t the Exchange fr publicatin nline in accrdance with guidance frm the Exchange and t ptential enrllees in hard cpy upn request. In the prvider directry, a QHP issuer must identify prviders that are nt accepting new patients. AID has the fllwing additinal requirements in regard t prvider directries: Online prvider directries must be available in Spanish. The directry search must include the ability t filter by each categry f ECP. The directry search must include an indicatin f part-time r full-time as well as after-hurs availability as reprted by prviders. Appendix 5 Netwrk Adequacy Guidelines and Targets Page 6 f 7

7 Arkansas Health Care Independence Prgram ( Private Optin ) Prpsed Evaluatin fr Sectin 1115 Demnstratin Waiver February 2014 Specialty Services AID is in the prcess f develping a rule with guidelines fr in-state cverage f specialty services (i.e. transplant, burn center), including services prvided at Centers f Excellence. Mre details frthcming. Appendix 5 Netwrk Adequacy Guidelines and Targets Page 7 f 7