Network Adequacy Advisory Council Introduction & Overview 2 - PowerPoint PPT Presentation

1 Network Adequacy Advisory Council Introduction & Overview

2 Network Adequacy Overview & Plan Year 2020 Standards

Network Adequacy CMS ECP/Network CMS Adequacy Silver State ECP/Network Template Health Adequacy Exchange Standards Network Adequacy Nevada Service Area Statutes & Regulations Federally Facilitated Market Place FFM

4 2020 Network Adequacy Standards Metro Micro Rural CEAC Max Max Max Max Max Max Max Max Specialty Time Distance Time Distance Time Distance Time Distance (Mins) (Miles) (Mins) (Miles) (Mins) (Miles) (Mins) (Miles) 15 10 30 20 40 30 70 60 Primary Care 60 40 100 75 110 90 145 130 Endocrinology 60 40 100 75 110 90 145 130 Infectious Diseases 45 30 60 45 75 60 110 100 Psychiatrist 45 30 60 45 75 60 110 100 Psychologist Licensed Clinical Social 45 30 60 45 75 60 110 100 Worker (LCSW) Oncology ‐ 45 30 60 45 75 60 110 100 Medical/Surgical Oncology ‐ 60 40 100 75 110 90 145 130 Radiation/Radiology 25 15 30 20 40 30 105 90 Pediatrics 60 40 100 75 110 90 145 130 Rheumatology 45 30 80 60 75 60 110 100 Hospitals 45 30 80 60 90 75 125 110 Outpatient Dialysis

5 SPECIALTY CODES 001 General Practice STANDARDS 002 Family Medicine 003 Internal Medicine Primary Care 005 Primary Care – Physician Assistant Endocrinology S E R V I C E A R E A 006 Primary Care – Nurse Practitioner Infectious Diseases 012 Endocrinology Mental Health METRICS 017 Infectious Diseases Oncology – 029 Psychiatry Time Medical/Surgery 102 Licensed Clinical Social Workers Distance Oncology – 103 Psychology Radiation/Radiation 021 Medical & Surgical Oncology Pediatrics 022 Radiation Oncology Rheumatology 101 Pediatrics ‐ Routine/Primary Care 031 Rheumatology Hospitals 040 General Acute Care Hospital Outpatient Dialysis 043 Critical Services – ICU 044 Outpatient Dialysis

6 2020 Essential Community Provider Standards A carrier must:  Contract with at least 30% of available Essential Community Providers (ECP) in each plan’s service area  Offer contracts in good faith to all available Indian health care providers in the service area  Offer contracts in good faith to at least one ECP in each category in each county in the service area.  ECP Categories: Family Planning Providers, Federally Qualified Health Center (FQHC), Hospitals, Indian Health Care Providers, Ryan White Providers, and Other ECP Providers  Offers contracts in good faith to all available ECPs in all counties designated as Counties with Extreme Access Considerations (CEAC) included in the plan’s service area

7 Network Adequacy Market Data

8 Insurance Coverage Snapshot Individual Market 4% Small Group Market 3% Tricare/ VA Health Care (other public) Uninsured Estimate 4% 11% Large Group Market (Fully Medicare Insured) 12% 13% Group Market (Self Funded) 31% Medicaid / CHIP 22% **This snapshot represents an estimate of the overall insurance coverage in the state of Nevada using data from a variety of sources. The accuracy of this snapshot is dependent on the accuracy of the data provided by each of the individual sources.

9 Plan Offerings by County Individual Market On Exchange On Exchange Off Exchange 16 PY PY PY PY County 14 2018 2019 2018 2019 12 Carson 10 8 City 4 5 46 28 6 4 Clark 14 14 40 25 2 0 Carson City Clark Douglas Nye Storey Washoe All Other Douglas 4 5 46 28 Off Exchange Nye 14 14 13 6 60 50 Storey 4 5 46 28 40 30 20 Washoe 14 14 59 34 10 0 All Other 4 5 0 1 Carson City Clark Douglas Nye Storey Washoe All Other PY 2018 PY 2019 **Carriers offering catastrophic plans only are not included in this data set.

10 Plan Offerings by County Small Employer Group Market County PY 2018 PY 2019 Off Exchange Carson City 217 190 250 Churchill 157 138 Clark 212 203 200 Douglas 217 189 Elko 135 138 Esmeralda 157 138 150 Eureka 157 138 Humboldt 157 138 100 Lander 157 138 Lincoln 157 138 Lyon 217 189 50 Mineral 157 138 Nye 212 206 0 Pershing 157 138 Storey 217 189 Washoe 240 213 PY 2018 PY 2019 White Pine 135 138 **Carriers offering catastrophic plans only are not included in this data set.

11 Network Adequacy Market Changes & Methodolgies

12 Market Changes  Associated Health Plans  Short Term Plans  Stop Loss Regulation  Nevada Care Plan/Sprinkle Care/Public Option

13 Network Adequacy Methodologies • Geographic Criteria • Provider to Enrollee Ratios • PCP – 1:1,200, 1:5,500, 1:2,500 • PCP Extender: 1:1,500, 1:1,800, 1:2,000 • Wait time requirements based on type of appointment • Routine Care: 7 – 30 days • Emergent or urgent care – 24 to 48 hours • Preventative Care – 30 – 120 days

14 Medicaid Standards Table 3 ‐ 5 Access Standards for Appointment Availability Provider/Appointment Type Appointment Availability Standard Primary Care Providers 1:1,500 PCP Extenders 1:1,800 Dental (Routine) 1:1,500 Table 3 ‐ 6 Access Standards for the Time/Distance Analysis Provider Category Distance ‐ Based Access Standard Primary Care Providers 1 provider within 25 miles PCP Extenders 1 provider within 25 miles Table 3 ‐ 7 Access Standards for Appointment Availability Provider/Appointment Type Appointment Availability Standard PCP Appointments (Routine) 2 weeks (or 14 calendar days) Specialists (Routine) 30 calendar days Dental (Routine) 30 calendar days Prenatal Care – 1 st & 2 nd Trimester 7 calendar days Prenatal Care – 3 rd Trimester 3 calendar days Source: SFY 2014‐2015 Provider Network Access Analysis

15 Additional Information  SSHIX Enrollment Numbers  2020 – SSHIX Platform change  The State Flexibility to Stabilize the Market Grant Program  Upcoming Legislation

16 Questions

17 Appendix

18 CMS Network Adequacy Template 057 Ambulatory Health Care Facilities ‐ 001 General Practice 018 Nephrology 040 General Acute Care Hospital Infusion Therapy/Oncology/Radiology 002 Family Medicine 019 Neurology 041 Cardiac Surgery Program 061 Heart Transplant Program 003 Internal Medicine 020 Neurological Surgery 042 Cardiac Catheterization Services 062 Heart/Lung Transplant Program 021 Medical Oncology & 043 Critical Care Services ‐ 004 Geriatrics 064 Kidney Transplant Program Surgical Oncology Intensive Care Units 005 Primary Care ‐ Physician 022 Radiation Oncology 044 Outpatient Dialysis 065 Liver Transplant Program Assistant 006 Primary Care ‐ Nurse 023 Ophthalmology 045 Surgical Services 066 Lung Transplant Program Practitioner 007 Allergy and Immunology 025 Orthopedic Surgery 046 Skilled Nursing Facilities 067 Pancreas Transplant Program 026 Physical Medicine & 008 Cardiovascular Disease 047 Diagnostic Radiology 000 OTHER Rehabilitation 101 Pediatrics ‐ Routine/Primary 010 Chiropractic 027 Plastic Surgery 048 Mammography Care 011 Dermatology 028 Podiatry 049 Physical Therapy 102 Licensed Clinical Social Workers 012 Endocrinology 029 Psychiatry 050 Occupational Therapist 103 Psychology 013 ENT/Otolaryngology 030 Pulmonology 051 Speech Therapy Dental ‐ General 014 Gastroenterology 031 Rheumatology 052 Inpatient Psychiatry Dental ‐ Orthodontist 015 General Surgery 033 Urology 054 Orthotics and Prosthetics Dental ‐ Periodontist 016 Gynecology (OB/GYN) 034 Vascular Surgery 055 Home Health Dental – Endodontist 017 Infectious Diseases 035 Cardiothoracic Surgery 056 Durable Medical Equipment Pharmacy

19 Essential Community Provider (ECP) Categories Major ECP Category ECP Provider Types Family Planning Providers Title X Family Planning Clinics and Title X “Look ‐ Alike” Family Planning Clinics Federally Qualified Health FQHC and FQHC “Look ‐ Alike” Clinics, Outpatient health Center (FQHC) programs/facilities operated by Indian tribes, tribal organizations, programs operated by Urban Indian Organizations Hospitals Disproportionate Share Hospital (DSH) and DSH ‐ eligible Hospitals, Children’s Hospitals, Rural Referral Centers, Sole Community Hospitals, Free ‐ standing Cancer Centers, Critical Access Hospitals Indian Health Care Indian Health Service (IHS providers), Indian Tribes, Tribal Providers organizations, and urban Indian Organizations Ryan White Providers Ryan White HIV/AIDS Program Providers Other ECP Providers STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, Community Mental Health Centers, Rural Health Clinics, and other entities that serve predominantly low ‐ income, medically underserved individuals