Need an escape from crowded malls, holiday meal planning and travel plans? We’ve got the solution: escape to a quiet corner of your home with steaming cup of hot coco, a warm blanket and hundreds of pages of proposed federal regulations. Tempting, right? Well, in case this activity doesn’t make it to the top of your to-do list this month, we’ve outlined the need-to-know facts and important opportunities for consumer advocates to weigh in on strengthening federal network adequacy requirements.

When consumers enroll in a health insurance plan, they are entitled to an adequate network that has a sufficient number of providers to deliver the health care services included in the plan’s benefit package. Over the past year, due to the existing feedback loops capturing consumers’ experience, advocates across the nation have reported a number of cases where consumers enrolled in new health plans through Marketplaces found that their plan did not meet their care needs as a result of limited network of providers. To ensure consumers have confidence they can access needed care in a timely manner under the plan of their choice, the Centers for Medicare and Medicaid Services (CMS) recently released a proposed regulation to strengthen network adequacy requirements. This is a step in the right direction, but there is more work to be done to ensure that consumers have access to robust networks that meet their care needs. Below are the key highlights on the new network adequacy requirements.

Essential Community Provider (ECP) Requirements: CMS expands the list of ECP’s categories and types to include ECPs that are state-owned, government, and not-for-profit facilities including family planning service sites regardless of whether they receive federal funding under specific federal programs. This expansion would further ensure that Marketplace enrollees from low-income and racially diverse communities residing in low-income zip codes or health professional shortage areas have access to needed care services in a timely manner.

Provider directory requirements: CMS requires that the provider directories must be updated at least once a month and available online to both enrollees and consumers shopping for coverage without requirements to log on or enter a password or a policy number to ensure consumers have an up-to-date, accurate and complete provider directory.

Network adequacy requirements: CMS clarifies that out-of-network providers cannot be counted in determining network adequacy. This would prevent any confusion consumers might face when accessing care. Furthermore, CMS is waiting for the results of the National Association of Insurance Commissioners (NAIC)’ revision of its network adequacy model act before proposing significant changes in these requirements.

This is an opportunity for consumer advocates to weigh in to influence the final rule. A new report on states’ oversight of health plan network adequacy conducted by the NAIC consumer representatives highlights state approaches to regulating and monitoring the adequacy of health plan provider networks. The report also includes a set of recommendations for improved oversight, such as:

(1)    Set clear quantitative standards for network adequacy to ensure consumers have access to needed care in a timely manner. These standards could include: minimum numbers and types of providers in the network, time and distance standards for services, and maximum appointment waiting times.

(2)    Develop stronger language on transparency regarding the type of plans being sold and the accuracy of plan provider directories to ensure that consumers can make the right choice when selecting health plans for themselves and their families. Consumers need reliable, easy-to-use information in order to make optimal choices – information that is not available in the Marketplaces today.

(3)    Create provisions that protect consumers from surprise “balance billing by out-of-network providers to reduce the burden of unexpected and expensive bills consumers might face at a time when they are most vulnerable.

(4)    Create provisions that ensure continuity of care protections for consumers. Provider networks can change over the course of the plan year for any reason, including because a provider chooses to leave the network. A grace period with a provider who leaves the network before transitioning to another in-network provider would help ensure continuity of care in these situations. This would be particularly helpful for people with chronic conditions.  

This report is a helpful resource as we are working on comments to improve the proposed regulations.

If you have questions or ideas for future materials on network adequacy, please contact Quynh Chi Nguyen, Program & Policy Associate; Staff Lead, Health Equity at qnguyen@communitycatalyst.org.

The holiday season brings many traditions to look forward to, such as spending time with family and exchanging gifts. There are also some less-favored traditions, though, such as the deluge of holiday-themed advertisements. Viewing the same images and hearing the same messages repeatedly can make anyone want to put on their blinders, plug their ears, and tune them out!

When consumer health advocates began planning for the Affordable Care Act’s second open enrollment period, advocates hypothesized that consumers who hadn’t enrolled in the previous open enrollment period may feel the same way that average holiday-shoppers feel – bombarded by the same messages that simply don’t resonate with them, and moreover, cause them to stop listening. To help motivate these consumers to enroll, the advocacy community felt that new messages needed to be created that would tap into the current feelings of the uninsured about having health insurance.

During the summer of 2014, the Robert Wood Johnson Foundation worked with PerryUndem and GMMB to conduct consumer focus groups and a national poll of uninsured individuals to better understand their feelings and attitudes toward having health insurance. Separate focus groups and polling were conducted with Spanish-dominant, uninsured Hispanics as well. Although the participants agreed that having health insurance is important, many of them firmly believed that they could not fit health insurance into their budgets. Overall, they found three messages about health insurance options were the most motivating: 1) there are low-cost health plans, 2) you can get financial help and 3) in-person assistance is available.

Based on their findings, RWJF launched a new website, TalkHealthInsuranceToMe.org, which educates consumers about these three aspects of the law and provides communications resources for partners to spread the word. The site provides a roadmap that walks consumers through information about the low-cost plans available through the Marketplace, eligibility information for financial help, and ways to find local, in-person assistance. The site also provides tools to help consumers determine how much financial help they are eligible to receive.

The partner-focused side of TalkHealthInsuranceToMe.org includes an outreach toolkit full of creative and innovative communications resources for advocates, enrollment assisters and other enrollment stakeholders. These resources are all available in both English and Spanish. In addition, RWJF has launched a digital and radio advertising campaign in federally-facilitated Marketplace states to help spread the word and encourage consumers to check out their options.

While the ACA has succeeded in enrolling millions of Americans in quality, affordable health coverage, there are still many who remain uninsured, due to perceptions of health insurance being unattainable, unaffordable, or both. Messaging aimed at these consumers should incorporate their current feelings and attitudes toward health insurance in order to be effective. Thanks to the leadership of the Robert Wood Johnson Foundation, we can determine that emphasizing low-cost plans, the availability of financial help to pay for plan costs and in-person assistance to help navigate coverage options, are the messages that will be most effective at addressing attitudinal barriers to enrollment. The wealth of resources available at TalkHealthInsuranceToMe.org provides the enrollment community with ways to message ACA enrollment that will make the remaining uninsured stop tuning out and start listening.

With open enrollment in full swing, consumer health advocates are ramping up their outreach to diverse populations that continue to have disproportionately high rates of uninsurance.

 Latinos in particular are more likely to be uninsured, with one in three Latinos lacking coverage nationally. While some states have made great progress in lowering the uninsured rate—states that closed the coverage gap have seen the uninsurance rate among Latinos drop from 36 percent to 23 percent— there is still a lot more work to do to ensure all Latinos can gain access to coverage. 

According to recent research, while most uninsured Latinos recognize the value of having health insurance and are interested in seeking health insurance options, 7.6 million o f an estimated 10.2 million of uninsured Latinos who are eligible for Medicaid or financial help to pay for coverage continue to face barriers to enrolling in coverage:

  • Lack of Awareness: According to a national poll conducted by the Robert Wood Johnson Foundation (RWJF), 81 percent of participants indicated that they do not know enough about the ACA, 78 percent do not know that the ACA provides financial help, and 66 percent do not know free, in-person assistance is available to help people apply for coverage. According to the same RWJF poll, when asked why they do not have insurance, 36 percent of respondents said they cannot afford insurance or they would not qualify. There is lack of awareness among Latinos about the availability of advanced premium tax credits (APTCs) for legal immigrants even if their income is below 100 percent Federal Poverty Level (FPL) and even if they are not eligible for Medicaid or CHIP under the five year bar.
  • Health literacy: Latinos are less likely to understand basic health insurance concepts than white, non-Hispanics. Additionally, some members of the Latino community view health insurance as transactional – something they should pay for as they go.
  • Immigration status: Mixed status families (i.e. families or households comprised of undocumented immigrants and United States residents) fear their undocumented relatives will be deported if they apply for insurance coverage and provide information about their household to the Marketplaces.
  • Language: There is limited access to accurate Spanish-language materials about the enrollment process. Additionally, CuidadoDeSalud.gov (the Spanish version of healthcare.gov) did not launch until December last year, which limited access to information about open enrollment for native Spanish Speakers.

While there are significant barriers to address in outreach to Latino communities, advocates around the country successfully employed essential strategies to reach uninsured Latinos and help them gain access to health care. (Learn more about these strategies and the outcomes they’ve produced by following the links below.):

  • Increasing health literacy and awareness through radio and television: The Colorado Consumer Health Initiative’s Latino Media Project in partnership with Adelante con la Salud (Latino Health Care Engagement Project) worked together to successfully educate Latinos in Colorado about the benefits of the ACA. With the help from Health Care for All Massachusetts (HCFA), they collected success stories about clients who gained coverage, both through expanded access to Medicaid and through financial help. In addition, educational messages about how Latinos benefit from the ACA were also disseminated through radio and television channels in both English and Spanish.
  • Engaging the faith-based community through education and enrollment events: UHCAN Ohio built strong relationships with community and faith based organizations by educating organizations about the ACA and partnering with them in Marketplace outreach, enrollment, and follow-up efforts recruiting some in Medicaid and marketplace outreach, enrollment, and follow-up efforts. Some community and faith groups then hosted enrollment events and others became certified application counselors. With the relationships they’ve already had with the local community, they partnered with church leaders in Latino communities to help them serve as health care resources for their congregations.
  • Training the trainer: The Oregon Latino Health Coalition hosted a conference to train 200 community health workers on how to assist Latino families with enrollment. In Florida, groups like the Epilepsy Foundation of Florida trained Navigators and teaming up with hospitals to reach Latinos.
  • In-person assistance: A personal touch is crucial during successful enrollment. Recent message research has shown that many members of the Latino population value a human interaction to answer questions and allay fears surrounding the enrollment process.
  • Using trusted messengers: the Latino community almost unanimously point to their social circle as their first and most trusted source of information

While it was difficult for advocates to reach and enroll some populations, especially the Latino population, the examples above can provide a roadmap to effectively working with the Latino population. For the second open enrollment period, advocates will need to continue focusing on outreach efforts for the uninsured Latino population, and use the information gained through polling and message research to pivot their efforts toward improving health literacy and adding a personal touch to enrollment assistance. 

These days, when we shop for even the smallest items, we have online reviews to help us find the best deals. But when it comes to the big-ticket item called Medicaid managed care, it's been a lot harder. Consumer advocates and other stakeholders have struggled to locate information on the performance of the multistate companies that are increasingly winning state contracts to manage Medicaid programs. Without this information, it's impossible to get a complete picture of how well a managed care company is likely to serve consumers.

In this season of giving, Community Catalyst has teamed up with the Kaiser Family Foundation to create an online tool that gathers in one place, for the first time, key data on the records of these companies. The Medicaid Managed Care Market Tracker includes quality scores and state-imposed sanctions. The tracker also enables comparisons across states' Medicaid managed care programs, including network access standards and the percent of premiums that go to care versus profits. All of this can help ensure consumers – both individuals and states – are getting their money's worth.

More than half of Medicaid beneficiaries are already in risk-based managed care plans, and states are rapidly expanding managed care to seniors and people with disabilities. In many states, this is tied to closing the coverage gap or demonstration projects for people eligible for both Medicaid and Medicare. Medicaid managed care can improve coordination, quality and efficiency of services. But it can also be risky for consumers, if the companies put profits ahead of people.

The Medicaid Managed Care Market Tracker lets you peer inside the wrapping of these companies.

For example, you can learn that from 2010 through 2013, for-profit UnitedHealth Group plans were sanctioned in seven states for offenses ranging from improperly denying speech therapy services in Florida (fined $1,305,000) to failing to meet standards for children's preventive services and vaccinations in Arizona (fined $200,000). Or that Molina's Texas plan paid the largest state fine during that period: nearly $3 million for problems including blocking access to needed medications, a skimpy provider network and poor handling of consumer complaints.

You can also learn that UnitedHealth's Rhode Island plan, which did not face any sanctions, received one of the highest overall quality scores – 85.5 out of 100 – from the National Committee for Quality Assurance. The plans scoring higher were all non-profits.

Other data show some states are paying a high price for having the companies manage their Medicaid programs. For example, in Delaware and Nevada, the companies took nearly 25 percent of taxpayer-supported premiums off the top, spending only 75 percent of premiums on care for state residents. These numbers cry out for closer examination of whether consumers are getting the quality and quantity of care they need.

Here are some more ways to use the new tool:

  • Check out plans operating in your state or planning to bid on business in your state
  • Identify how your state's managed care standards stack up to those in other states and advocate for stronger standards
  • Identify the parent companies of plans in your state and their performance, so you can learn more about their corporate standards
  • Educate policymakers as they consider expanding Medicaid managed care and/or contracting with new plans
  • Highlight promising and problematic plans for media
  • Advocate for more public accountability for the public dollars spent on managed care

To learn more about the tool, please join a webinar hosted by Kaiser Family Foundation on Thursday, December 11 at 12:30 PM EST.

Now if we could only turn this into an app....

As the fight to close the coverage gap continues in 23 states, critics are openly questioning the value of Medicaid and even claiming that it is not better than being uninsured. But recent data unsurprisingly reveals that potential low-income beneficiaries do not quite see it that way.

While we already know that strong empirical evidence confirms Medicaid’s effectiveness at improving access to care, health outcomes, and financial security for its beneficiaries, this recent study provides a fresh perspective that too often gets lost in the politically-charged policy sphere: consumers’ actual experience and perceptions of Medicaid. The study surveyed low-income adults from three southern states who are either Medicaid beneficiaries or would be eligible for Medicaid coverage if their state closed the gap.

According to the study, 80 percent of respondents supported closing the coverage gap and covering more people through the Medicaid program. Between Medicaid and private insurance, the latter had an edge in being able to see the “doctors you want, without having to wait too long.” However, Medicaid ranked higher in enabling beneficiaries to “be able to afford the health care you need,” and on the overall question of “quality of health care” (see Figure 1).

Source: Authors’ analysis of survey data of 2,864 low-income adults (ages 19–64) in Texas, Arkansas, and Kentucky. Health Affairs, October 2014.

When comparing Medicaid with no insurance, more than 90 percent of respondents favored Medicaid across the board in quality, affordability, and being able to access a doctor that respects his/her patients. The study also reveals that despite how much they stand to gain from Medicaid, most low-income people are unaware or misinformed whether or not their state has closed the gap. Thus, while consumers favor improved Medicaid coverage, they are marginalized in the very policy discussions that will impact their health and lives. This discrepancy underscores the critical role that health care reform advocates continue to play in elevating the consumer voice, and particularly the voices of the most vulnerable among us, for improving their access and experience of health care.