Comments to NH Insurance Department re: Proposed New Model for Network Adequacy September 8, 2015

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1 Comments to NH Insurance Department re: Proposed New Model for Network Adequacy September 8, 2015 Thank you for the ongoing opportunity to provide feedback on the Department s new network adequacy framework. NH Voices for Health (VOICES) appreciates the Department s willingness to consider inquiries and input from stakeholders as it advances the details of the proposed new rule. Given the significance of the network adequacy rule and its bearing on consumers here in New Hampshire, and in light of the unique nature of the new framework the Department has proposed, VOICES has encouraged consumers, health professionals, other advocates, and industry associations to review the details of the new rule with an eye toward identifying potential areas for further consideration. The comments and questions below reflect feedback VOICES has gathered since late July via stakeholder input calls and meetings. We recommended that all the individuals and organizations with whom we connected also submit feedback directly to the Department. As a result, we expect that the Department has heard from a range of individuals in recent weeks and may now already be familiar with some of the feedback detailed below. In our outreach to stakeholders, many were previously unaware of the Department s initiative to revise the rule, however, all offered significant feedback. Given the innovative nature of the proposed new framework and the need for input from a diverse range of individuals and organizations, we hope that the Department will convene at least one more Network Adequacy Working Group meeting after September and before initiating the formal rulemaking process. It is evident that more stakeholder engagement is necessary and would be of benefit to all. The comments below reflect the combined feedback VOICES has gathered from the following organizations: NH Physical Therapy Association, the NH Psychological Association, The Counseling Center of Nashua, Community Bridges, New Futures, Planned Parenthood of Northern New England, NH Children s Behavioral Health Collaborative, Bi- State Primary Care Association, The Citizen s Health Initiative at the University of New Hampshire, American Heart Association - NH, and the Concord Feminist Health Center. Some of the feedback below is shared by a number of stakeholders, other elements of the feedback are unique to their respective members/constituencies. Appendix A contains more detailed feedback adapted from a few specific organizations. That VOICES has combined this feedback should not be construed as signaling the blanket endorsement of each of these issues by all contributing organizations.

2 Provider Accessibility and Related Transparency Concerns VOICES comments to the Department in August 2014 respectfully requested that it consider including a requirement in the new rule for the standardization of information pertaining to the restrictiveness and breadth of plan networks. There continues to be broad stakeholder support for such measures. The information detailed below plays an essential role in enabling consumers to effectively evaluate the networks of any plan they are considering purchasing, and likewise equips consumers with the information they need to more appropriately access services. With that in mind, VOICES asks the Department to factor the following information into the new rule: o Insurers should provide direct access to their network lists online and in hardcopy, without requiring consumers to enroll in a plan or create and/or login to an online account to access them. Network lists should be disclosed in a standardized manner, clearly identifying which networks apply to which plans, and allowing consumers to search networks and plans by specific providers. o Standardized provider directories should include information about specialties, availability to new patients, hours of operation, languages spoken, institutional affiliations, available interpreter services, language and communication assistance services, accessibility of physical facilities, and information about any telemedicine services, for example. o As provider directories and network listings represent only a snapshot in time, such information should be updated on a monthly basis to ensure that consumers enroll in plans, and seek care, equipped with advance knowledge of the network of providers and services available to them. Consumer Protections for Out- of- Network Services It would be helpful if the Department would share more information about the manner in which the new rule will address consumer protections for out- of- network services. o In the Department s July 10, 2015 responses to comments from the Working Group, there is a note indicating that the "NHID does seek certain member protections, including holding the member harmless in special cases where the NA requirement is not met - (major change in network due to contract termination - non- contracting anesthesiologist, pathologist, radiologist during surgery)." ( Network Adequacy Working Group: Public Comments and Responses ) Can the Department provide a full list of those special cases? Will those cases be enumerated in the rule? What kind of protection will be afforded consumers who become one of the special cases? Will applicable situations result in relevant services being billed at in- network rates? 2

3 Provider Capacity and Definitions For services that fall under that special cases category, will the rule specify if and how carriers will inform members of those protections (i.e. advance disclosure)? Does the Department still plan to assess provider capacity based on NCQA/URAC standards? Stakeholders would benefit from additional information regarding provider definitions, with particular emphasis on individual provider / practice level and how those distinctions would factor into carrier contracting. The Department s proposal to require carriers to contract with at least 30% of providers for core services, where at least three independent providers exist, is met with concern from some stakeholders who feel that a contract rate of 50% would be more appropriate. It is understood that the Department is considering a 50% rate for some situations. More information about the circumstances in which the 50% rate would apply would help stakeholders assess whether it would be adequate. It would also be helpful to understand if the Department will include measures to encourage carriers to contract with small business / provider groups to protect and advance a diversity of delivery options (both with respect to the kind of organization delivering the service, and the geographic location of the provider offering the service). Having such measures in place will be particularly important going forward, as it is reasonable to expect continued innovation in the delivery of care. Clarification and Amendment of Enumerated Services How would the list of services categorized by appropriate proximity to members work in practice? o How will carriers demonstrate that the proposed plan networks include access to these services in the expected proximity to members? o How will the new rule impact billing practices? Stakeholders have also flagged the need to ensure that descriptions of services are clinical, therein reducing the likelihood of varying interpretations by carriers (the term therapeutic SUD services was flagged as one such example of a nonclinical term that could result in varied interpretations). A number of stakeholders raised concern that the decision to rely on claims data will result in the exclusion of certain services that are widely used, but not previously billed/covered by insurance. For example, MH/SUD services are often grant funded or private pay only. Or, looking to mental health services for children, a dearth of providers in NH means those services are underrepresented in the data. This does not reflect the direction in which access to those services needs to move. Relying upon claims data has the potential to solidify current inadequacies in available services and providers. 3

4 In the Department s excel workbook of model service codes, there is a note indicating that, "only the most frequent services are described. The model assumes that a network of practitioners who deliver these services will also deliver the less frequent services that comprise their normal practice." o If the list is not comprehensive, what ensures that other unlisted services will be in network at the appropriate proximity to the member? o There is recognition among stakeholders of the important distinction between setting a minimum standard for a provider network and determining benefits coverage. However, many share VOICES concern that once a minimum set of services is defined, carriers might have the option to build plans that classify other less frequent, but nevertheless key, services as out- of- network, leaving consumers to pay out of pocket for them. o How will the new rule protect access to those less frequent services that are currently included in normal practice but that are not listed in the workbook? o What would the process be for amending the list of services, particularly as types of care evolve in the future? The Department is asked to consider listing MH/SUD emergency treatment separately, as this has the potential to address the problem of carriers covering ER visits for overdose, for example, but denying coverage for necessary inpatient detox and/or residential treatment. The Core categories of services listed by the Department should be amended such that Obstetrics becomes Obstetrics and Gynecology. Excluding gynecology from the list overlooks the reality that many women choose to see their OB/GYN for primary care services. All methods of contraception should be included in the CPT code workbook. It is important to ensure that the listing of services in the workbook is not used to limit choice for women. CPT codes for abortion services should be included in the workbook. This is a common medical procedure and one where timely access to a nearby provider is vital. Compliance with Federal Parity Standards It is critically important that the NHID factor federal parity standards into the classification of mental health and substance use disorder benefits (MH/SUD) as Core or Common, ensuring that the new rule complies with existing law. VOICES is aware that the Department is consulting with appropriate experts and advocates, including the Legal Action Center, on this issue and we hope the feedback they provide will help determine the final form of the new rule. Impact on Current Future Delivery System Innovations Stakeholders also shared concerns that the new rule must balance the need for increased competition among providers aimed at lowering the cost of care, with 4

5 ongoing and future initiatives here in NH to promote integrated care. For example, how will the new rule impact the Department of Health and Human Services pending 1115 demonstration waiver? Larger provider groups are often in the best position to focus on care integration, particularly as it pertains to the coordination of care for patients with complex and co- occurring health issues. Would the implementation of the new framework adversely impact important integrated care initiatives in NH? As mentioned above, we encourage the Department to convene the Network Adequacy Working Group at least one more time following the September meeting and before the formal rulemaking process begins. This will give stakeholders a chance to reflect upon the Department s responses to this feedback, and identify other potential areas of concern. Thank you again for inviting stakeholders to participate in this process. We appreciate the opportunity to comment on the Department s proposed framework and look forward to continuing to work with you on this issue in the coming weeks. Sincerely, Evelyn Aissa Advocacy Director 5

6 Appendix A Adapted Stakeholder Input re: CPT Code Listings All feedback detailed below is adapted from comments shared with VOICES by other stakeholders. Those stakeholders include the NH Physical Therapy Association, the NH Psychological Association, The Counseling Center of Nashua, Community Bridges, New Futures, and Planned Parenthood of Northern New England. Input adapted from the NH Psychological Association and The Counseling Center of Nashua: CPT codes should be consistent with AMA wording when possible. o In the core category, the 97xxx CPT series are not generally specific to Physical Therapy Procedures. Although it is understandable this may be necessary if the rehabilitation specialties are split by service level, it would be best to minimize this. We recommend removing the words not requiring specialized equipment from the Core listings and listing the exception language of specialized equipment only in the common area listing. o (Manual Therapy): The AMA does not indicate any number of regions. Current workbook language should be changed so as to be consistent with the AMA. The Department should provide more information regarding the definition of specialized equipment (Aquatic Therapy) should be moved from core to common as pool services may not be available in all HSAs and may be cost prohibitive for some facilities to establish. CPT (Developmental Screening) should be moved from common to core in order to align with the intention of existing NH language. o IDEA regulatory language indicates developmental services are designated to be in a Natural Environment which references places where the child s age peers without disabilities live, play, and grow (most often considered the home ). o Not all of these services are delivered through commercial insurance, but a significant portion of services may be delivered via networks. Core services should include: developmental screening, mental health diagnosis and treatment 0-5 specific. This is important as many community mental health centers do no provide services to younger children. Common services should include: OT, PT, and speech therapy, and should specify pediatric evaluation and treatment, therapeutic procedures and activities, pool physical therapy, and orthotics training. Feeding and swallowing evaluation and treatment should also be included for speech and OT. Specialized services should include: Genetic testing, diagnostic assessment (e.g. for Autism), auditory rehab, and augmentative communication assessment. 6

7 There should also be specific language about how definitions, codes, and other elements not included in the current CPT workbook are added (and/or changed). There is no specific mention of how this will be handled (such as a rule making/temporary rule/public hearing process with required stakeholder involvement). For example, there are a significant number of CPT codes in the area of physical therapy which are not mentioned in current documents (likely based on frequency of use) which generally would appear consistent with inclusion in the Core category (such as CPT code Paraffin bath therapy, Whirlpool therapy, Iontophoresis, Group Therapy, Community/work reintegration, Wheelchair training, 97597/97598/97605/97606 Wound care and Negative Pressure, Orthotic training, and Prosthetic training). Input Adapted from the NH Psychological Association and The Counseling Center of Nashua: There is a need to incentivize specialists to join networks and mandating some level of contracting to ensure such providers are in network could benefit consumers. o NH does not differentiate between adult versus child psychiatry and the availability of child psychiatrists here is woefully inadequate. Unlike Maine and Massachusetts, where there is a special fee schedule for child psychiatrists delivering behavioral health services, there is no such thing in NH and thus limited ability to address the issue of low supply/high demand. In the absence of a special fee schedule for such practitioners, the incentive for more of them to work in NH will remain low. o The same issue applies to neuropsychology. At present, there is a 3 to 4 month waiting list in NH for related services, especially for autism spectrum disorder evaluations. NCQA guidelines for insurance plans seeking accreditation should be factored into the consideration of which CPT codes are core vs. common vs. specialized vs. highly specialized. The NCQA requires all insurance plans to have same day access to emergent behavioral health care, 48 hour access to urgent behavioral health care, and access within 10 days to routine care. It also requires that each "region" have a "high volume behavioral healthcare provider" contracted to deliver service within these standards. Those CPT codes which constitute same day emergent (within 6 hours), 48 hour urgent, and 10 day routine should be linked in some manner to the community standards algorithm. Specifically: o Primary and most common psychiatry codes for service are largely omitted from the current NHID workbook. o and are currently classified as common, but should be classified as core: These are both initial visit, diagnostic interview codes, that start evaluation relationship with psychopharm providers (a psychiatric APRN or psychiatrist). o is currently classified as common, but the E&M code for a new patient for the same service is omitted. Both of these codes should be classified as core as they need to be available in the immediate community. Having access to in an "adjacent community" overlooks the need for access to 7

8 behavioral health care. In rural Northern NH, adjacent communities may be all that is feasible, but from the Lakes Region south, there is no reason that these services could not be "core" and available within a patient s community. o Routine psychopharm related follow- up visit E&M codes between are currently omitted altogether. These services are routine and follow the initial diagnostic interview or evaluation process. These should also be classified as core services. o The Emergency Service Behavioral Health Code, S9485, is also omitted but should be included under Core services in order to meet NCQA established standards for same day (within 6 hour access), and 48 hours urgent access. It could be provided as a "core" service using NH telemedicine mandates even in regions were providers are not physically located within a community. o (psychological testing) is omitted and should be classified as common. o (neuropsychological testing) is omitted and should be classified as common or specialized given the shorter supply of neuropsychologists compared to clinical psychologists). As suggested above, including and would improve consumer access to these services, which are desperately needed for children being evaluated for autism spectrum disorders. o H0020 (methadone maintenance) is classified as "common", however, the more frequently used codes for both alcohol and opiate/suboxone detox and maintenance and intervention are omitted: H0007 (crisis intervention, alcohol and drug services), H0050 (alcohol and drug intervention services, per 15 minutes), H0033 (oral medicine administration, observation) and H0014 (ambulatory detox). These should all be included as "common" codes as they are nearly similar to methadone maintenance. The codes may not show up in reports run because these standard codes were discontinued by Medicare, but private insurance companies continue to use them for substance abuse and detox services. o H0020 is classified as both core and common. If it is classified as "core", so should all the H codes referenced in the prior paragraph. Ideally, all substance abuse services such as these should be "core" services, available in local communities, but the current standard is that people do drive up to 25 minutes to seek these services. Input Adapted from Planned Parenthood of Northern New England All methods of contraception should be included in the CPT code workbook (especially long- acting reversible contraception), regardless of how frequently those services are offered. A limited number of preventive visit codes are included in the current CPT service code workbook (99385, 99386, 99394, 99395, and 99396). However, codes to are absent. New patient codes ( ) should be included in core services, in addition to all the preventive visit codes. 8

9 CPT codes for abortion services are not included, despite the fact that this is a common medical procedure and one where timely access to a nearby provider is critical. Tobacco cessation visits (99407) are also not included in the current workbook. While these services are not billed with great frequency, they are likely being performed and this is an essential preventive code. Codes related to the identification and removal of simple lesions do not appear in the workbook but should be included. Those codes include: 54050, 56501, 57452, 57454, 57455, and