05-02-16 – Health Care Committee – OON – Consumer Health Assist and DOI Advisory Council
The interim health care committee met recently and focused on two issues very important to NVOS members:
1) Out of network complaints and the role of the Gov’s office for Consumer Health Assistance
2) The DOI’s new regulation on network adequacy and the Commissioner’s new advisory committee on the topic
Please see the summaries below and note the highlights where there is a request for action.
Overview of the Governor’s Office for Consumer Health Assistance
Janise Wiggins, L.S.W., M.P.A., Governor’s Consumer Health Advocate, Office of Minority Health, Office for Consumer Health Assistance, DHHS
The overarching goal of the Office is to assist consumers with access to care and unresolved bills associated with care. Ms. Wiggins gave a brief overview of the Office and its history:
- In 1999, The Office of Consumer Health Assistance was born out of the workers compensation privatization process.
- In 2001, the Bureau for Hospital Patients moved into the Office. The Bureau has one ombudsman who works with consumers who have issues related to hospital billing issues.
- In 2003, with the passage of AB 236, The Office was tasked with helping consumers access prescription drug cost assistance programs. Also in 2003, the Office began working with the Division of Insurance to review benefit denials by carriers. These most often deal with questions of medically necessary and experimental treatments.
- In 2005, legislation was passed that required all hospital admission and discharge paperwork and workers compensation forms to include contact information for the Office of Consumer Health Assistance; hospital waiting rooms are also required to post such information.
- In 2015, The Office received a grant from the Silver State Health Insurance Exchange to provide consumers assistance navigating and enrolling in Medicaid or QHPs through Nevada Health Link.
Ms. Wiggins provided the following statistics associated with the Office’s activities:
FY 2015:
– 14,231 calls received
– 490 walk ins
– 2,140 cases opened
– $3,375,000 saved in consumer health costs
– Assisted approximately 600 individuals and families with ACA enrollment
Ms. Wiggins stated that approximately 15-20% of cases received relating to billing issues are related to out of network or balanced billing. For FY 2016 to date, The Office has opened approximately 30 cases related to network adequacy and balance billing. Most of those cases involve an ER visit.
When handling billing complaints, The Office first tries to resolve the issue by contacting the carrier to see if the patient still has the ability to appeal for additional payment. The Office often tries to work with both the carrier and provider to see if they are willing to work out some kind of one-time contract to address the particular issue.
Ms. Wiggins presentation is attached. Note on the top slide on page 10 that she presented “orthopaedics” as the highest number of cases opened. We have requested a follow-up meeting with her during the week of May 9.
Overview and Discussion of Policies to Address the Adequacy of Health Insurance Provider Networks and Surprise Medical Bills
Alexia Emmermann, Esq., Insurance Counsel, Legal Section, Division of Insurance, Department of Business and Industry
Ms. Emmermann gave an overview of the process that led up to the passage of R049-14 and the requirements provided in the regulation. As you all klnow, NVOS took an active role (in concert with NSMA) via public meetings and comment letters during the development of this regulation.
Some key points from Ms. Emmermann’s presentation (attached):
- AB 425 of the 2013 Session moved the responsibility of network adequacy from the State Health of Board to the Division of Insurance
- For the purposes of determining adequacy of network, R049-14 adopts the 2017 Letter to Issuers in the Federally Facilitate Marketplace
- Federal standards apply to QHPs; Nevada has extended the standards to HMOs and PPOs, both on and off the exchange
- The 2017 Letter sets time and distance standards for certain specialties “which have historically raised network adequacy standards” – page 23 of the 2017 Letter
- Note: Orthopaedics is not included in these standards
- The federal standards as intended to be the floor in making determinations of network adequacy; regulators can set additional standards
- The regulation does not address balanced billing because it is out of the jurisdiction of the Division
- The regulation creates the Commissioner’s Network Adequacy Advisory Council
- Notice to submit applications for membership on the Council has been released and is attached. The deadline for submittal is May 16. Please let me know if you or someone in your office is interested in applying.
- Ms. Emmermann provided a Network Adequacy Timeline, which is attached
Overview and Discussion of Policies to Address the Adequacy of Health Insurance Provider Network and Surprise Medical Bills
Catherine O’Mara, Esq., Executive Director, Nevada State Medical Association
Ms. O’Mara spoke briefly on the topic of network adequacy and balanced billing, using the opportunity to point out the need for consumer education, which is the responsibility of the insurance carriers. Key points made by Ms. O’Mara:
- Network adequacy standards for ER are not included in state law or the regulation recently adopted, nor are they included in federal law or regulation
- Ms. O’Mara placed great emphasis on the need for patient and employer education at the time they purchase a plan. Consumers need to be educated on the costs associated with a high deductible plan. Many times, patient challenges are not a balanced billing issue, but rather a high deductible issue.
Janise Wiggins Office for Consumer Health Assistance Presentation