Advisory Council Introduction Data Overview 2 Life Health - - PowerPoint PPT Presentation

NetworkAdequacy AdvisoryCouncil

IntroductionDataOverview

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KimEverett– AssistantChiefInsuranceExaminer J

eremey Gladstone – Actuarial Analyst II

LifeHealthContacts

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NetworkAdequacy

OverviewPlanY ear2018 Standards

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NetworkAdequacy

Network Adequacy

CMS ECP/ Network Adequacy Standards Nevada Statutes Regulations SilverState Health Exchange ServiceArea Federally Facilitated MarketPlace FFM CMS ECP/ Network Adequacy Template

Type Specialty

M etro M icro Rural CEAC

Max Time (Mins) Max Distance (Miles) Max Time (Mins) Max Distance (Miles) Max Time (Mins) Max Distance (Miles) Max Time (Mins) Max Distance (Miles)

Provider PrimaryCare

15 10 30 20 40 30 70 60

Endocrinology

60 40 100 75 110 90 145 130

InfectiousDiseases

60 40 100 75 110 90 145 130

MentalHealth

45 30 60 45 75 60 110 100

Oncology- Medical/ Surgical

45 30 60 45 75 60 110 100

Oncology- Radiation/ Radiology

60 40 100 75 110 90 145 130

Pediatrics

25 15 30 20 40 30 105 90

Rheumatology

60 40 100 75 110 90 145 130

Facility Hospitals

45 30 80 60 75 60 110 100

OutpatientDialysis

45 30 80 60 90 75 125 110

2018NetworkAdequacyStandards

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SERVI CEAREA

STANDARDS PrimaryCare Endocrinology InfectiousDiseases MentalHealth Oncology– Medical/ S urgery Oncology– Radiation/ Radiation Pediatrics Rheumatology Hospitals OutpatientDialysis SPECIAL TYCODES

001GeneralPractice 002FamilyMedicine 003InternalMedicine 005PrimaryCare– PhysicianAssistant 006PrimaryCare– NursePractitioner 012Endocrinology 017InfectiousDiseases 029Psychiatry 102LicensedClinicalSocialWorkers 103Psychology 021MedicalSurgicalOncology 022RadiationOncology 101Pediatrics- Routine/ PrimaryCare 031Rheumatology 040GeneralAcuteCareHospital 043CriticalServices– ICU 044OutpatientDialysis

METRICS Time Distance

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2018EssentialCommunityProvider Standards

carriermust: Contractwithatleast30%ofavailableEssential

CommunityProviders(ECP)ineachplan’s

servicearea

Offercontractsingoodfaithtoallavailable

Indianhealthcareprovidersintheservicearea

OffercontractsingoodfaithtoatleastoneECP

ineachcategoryineachcounty intheservice area

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EssentialCommunityProvider(ECP)Categories

M ajor ECP Category ECP Provider Types Family Planning Providers Title X Family Planning Clinics and Title X “ Look-Alike” Family Planning Clinics Federally Qualified Health Center (FQHC) FQHC and FQHC “Look-Alike” Clinics, Outpatient health 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 Providers Indian Health Service (IHS providers), Indian Tribes, Tribal

• rganizations, 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

• ther entities that serve predominantly low-income, medically

underserved individuals

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NetworkAdequacy AnalysisDataSources

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CMSECP/ NetworkAdequacyTemplate

Essential Community Provider Template Network Adequacy Template

Nevada Declaration Document

Autism Provider Template Telehealth Services

Carrier Filing Documentation

Rate Review Template

NetworkAdequacyDataSources

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ConsolidatingAlloftheTemplatesAllows

theDivisionto:

Identifyprovider/ facilitydeficienciesthatexistmarketwide Analyzeproviders/ facilitiesnotincludedincurrentstandardstoassistin

settingappropriatemetricsfortimeanddistance

Provider/ Facilitycountsbystate,county,zipcode

CMSECP/ NetworkAdequacyTemplate

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CMSNetworkAdequacyTemplate

001GeneralPractice 018Nephrology 040GeneralAcuteCareHospital 057AmbulatoryHealthCareFacilities- InfusionTherapy/ Oncology/ Radiology 002FamilyMedicine 019Neurology 041CardiacSurgeryProgram 061HeartTransplantProgram 003InternalMedicine 020NeurologicalSurgery 042CardiacCatheterizationServices 062Heart/ LungTransplantProgram 004Geriatrics 021MedicalOncology SurgicalOncology 043CriticalCareServices- IntensiveCareUnits 064KidneyTransplantProgram 005PrimaryCare- Physician Assistant 022RadiationOncology 044OutpatientDialysis 065LiverTransplantProgram 006PrimaryCare- Nurse Practitioner 023Ophthalmology 045SurgicalServices 066LungTransplantProgram 007AllergyandImmunology 025OrthopedicSurgery 046SkilledNursingFacilities 067PancreasTransplantProgram 008CardiovascularDisease 026PhysicalMedicine Rehabilitation 047DiagnosticRadiology 000OTHER 010Chiropracty 027PlasticSurgery 048Mammography 101Pediatrics- Routine/ Primary Care 011Dermatology 028Podiatry 049PhysicalTherapy 102LicensedClinicalSocialWorkers 012Endocrinology 029Psychiatry 050OccupationalTherapist 103Psychology 013ENT/ Otolaryngology 030Pulmonology 051SpeechTherapy Dental- General 014Gastroenterology 031Rheumatology 052InpatientPsychiatry Dental- Orthodontist 015GeneralSurgery 033Urology 054OrthoticsandProsthetics Dental- Periodontist 016Gynecology(OB/ GYN) 034VascularSurgery 055HomeHealth Dental– Endodontist 017InfectiousDiseases 035CardiothoracicSurgery 056DurableMedicalEquipment Pharmacy 12

AutismProviderList

The division expanded this section to encompass more providers offering

autism services.

Please provide a list of all providers designated as providing autism services or autism applied behavioral analysis such as registered behavioral technician, behavior interventionists, board certified behavior analysts, or any other autism provider designation for each Network ID defined within the CMS Network ID T

• emplate. Use the Autism Provider T

emplate provided on the Division’s website.

Telehealth Providers

Carriers required to list Telehealth Providers as well as indicate in the CMS

ECP/ Network Adequacy Template any providers acting as a Distant site for Telehealth services.

NevadaDeclarationDocument

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PY2019DataTimeline

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02/ 2017 03/ 2017 04/ 2017 05/ 2017 06/ 2017 07/ 2017 08/ 2017 09/ 2017

1st PY 2019 NAAC M eeting February 13, 2017 DOI Guidance to Carriers M id-M arch QHP Submissions April 26, 2017 Off Exchange Submissions J une 1, 2017 Council Recommendations Due September 15, 2017

Questions

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