Health Insurance Exchanges: Submit Comments on Accurate Provider Directories

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at drdaviss@gmail.com.

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at drdaviss@gmail.com.

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at drdaviss@gmail.com.