Coverage for example in one market where we are the narrower provider we found they had no access to pet scans. Another glitch we found as their exclusive Network Provider they had not contracted with any Lamp Services or radiation therapy. We can provide these services but frankly getting Outpatient Lab testing at your hospital may not be as convenient as some of the labs that are available with better parking and hours. Finally id like to reemphasize the reality of the marketplace is that price dominates. Premiums is what people are most likely to look at. Those with low income still leave outofpocket medical expenses that are unaffordable below this operation. As a result, even modest out pocket costs create affordability programs. This is from one of our markets. A married couple. Income 48,000 a year. They chose a bronze plan. Their premium is subsidized. They have a 3,600 deductible and a 12,000 potential outofpocket maximum. If one of this group needed a jant re placement or hthe premiums, deductibles and expenses would result in 30,000. These high deductible plans not only are they unaffordable but they lead to poor care. Its well documents that when people lay seebing their care or they will have difficult adhe adhering to the treatment plans when faced with large outofpocket costs. Moving forward its important to develop policies based on antitotal information. The reality is that we need more rigorous information. We need to know whats working an not working around the nation. What works in one community may not work in another community. The one priority we have for education providing transparency for the consumer. So they know how available these providers will be to them. How much cost shares and the quality that can be provided by those providers. Is this more rigorous information. We believe its important to remain flexible to respond to any egregious situations coming up, responding with compassion to meet the patients needs as best we can. Thanks catherine. Lets turn to brian webb from naic. Thank you very much. Good afternoon everybody. Im with the National Association of insurance commissioners. We represent the commissioners from the 50 states. Washington d. C. , which just became more important to some people in the room last year. Also, the five u. S. Territories which is clarified last week are not states for title one of the Affordable Care act. One of our jobs to develop model law its, rules, regulations that states can use. Were bringing stakeholders from all over is number 74. The model advocacy act. It with a developed in 1996. Looking around the room it looks like half of you were in ginter garden. Were looking at it again see iffi ing if it needs to be updated. Making sure carriers when they set up their care is that theres reasonable insurance that somebody can be get to in tough numbers and types in a reasonable amount of team states can look at the networks to make sure that that definition of reasonable is reasonable. When you look at the time it takes people to get to them, any waiting periods, any distance issues that you make sure that everybody can get to somebody in a sufficient way. If not, if there is an insufficient network the carrier makes sure the patient can go to another doctor or provider and that they would be not charged more for going to them. They require the carriers to file an access plan with the commissioner prior to offering the new managed care plan. What goes in that is a description of the network and also say how they are going to monitor the network on an ongoing basis. What their egregious procedures will be if somebody has a problem or question about the network. Notification. How do they notify if theres a change. Also, the continuity of care if somebody is dropped how are you going to make sure that person gets the care they need through that provider or a separate provid provider. You want to make sure the contracts being set up are done in a zrim toor way. You want to make sure they are basically giving inducements to providers to make sure they cant discuss certain kinds of care. All of those are rolled together in our model act. About ten states have taken and adopted our model verbatim. Taken it just as it is. Another ten have something similar. Even in those 20 states through guidance and other adopted concepts. They work with the carriers. The carriers do use a lot of these standards in developing the networks. If you want a copy go to store and free. We also have a paper that we did on this going back a couple of free interest. We have set up a sub group that is currently doing regular phone calls. They are open phone calls. Anybody in this room is sit in them if you have Nothing Better with you to do with your lee. You can do that. Anybody and everybody can provide comments. Suggested changes. However you want to do it t. Weve gone through the carriers, providers, consumers, of course. Others that have come in and brought us our ideas. We will soon started the process that we need to update. One is the concept of essential community provider. Thats not something we were looking at before. Are those included in your networks. Are we applying it to all managed care. Some states only did it in the old Network Types of plans. Do you go out to ppo. Go out to everybody to pab sure everybody is doing with a they need tow dough. Were having another meeting at 1 00 on thursday when we start looking at amendments. We started receiving comments and we will see where we need to update our model. If you want information, the webb site is there. You can go and get the exact call in information. What are the issues . One is the flexibility to reflect state needs. This will always be our number one point we dont want a federal point. The government comes in and says this is exactly same and distance for each type of provider. I dont know about you but tw e wyoming is a tad different than los angeles. What about certain populations and maybe very populace areas but maybe some transportation issues. States have been looking at these issues and are best to address these issues given their needs. We need to balance. Theres no sense of going in because we need to balance quality, affordability, access. How do you do that in the model and make sure everyone is protected is our number one concern. We will be looking at teared networks. They are if you go to this group you pay this much, that group, this much. They are teiered up. How are those set up . Narrow networks. One issue in particular well be looking at in a couple of states, carriers said if you purchase in the state, we will cover you either as in network or out of network. If you go to any provider outside the state, we will not pay nothing. Not covered. Were going to have to look at that. Well also have to look at provider updates. I think that was already addr s addressed here. Cant have a free market when people cannot get access to information. We had that this year. It was a rough year trying to get plans on, get it run and get it out there. Weve got to do about thor open enrollment period. Consumers need to know if they purchase that plan is their provider in there or not. They need to have clear access. To tell you the truth, provide kers groups needs to make sure everybody has the information they need. If there are updates that those notifications are going out so the consumer is well aware of what their options are. We do want options. There are many plans and we will have more plans on the exchanges next year across the country. Are some of them narrow . Some are not narrow. Do people know the differences and accurate Consumer Education. Do they have the right choices before them . Another issue well be looking at is the surprise bills. How many of you like surprises . I like surprises but not when its a bill. This is when you go in for a procedure. Your doctor is in the network. Your hospital is in the network and your anesthesiologist is not. Thats called surprise. Youll be charged higher for that. States have been doing stuff on this n. Federal governments will be looking at to make sure of that. I will leave you with this last slide. If you have any questions please call joel ee. She was spupposed to be here. If you do have any questions, please call her. Shed be able to help you out. If you are you interested in this, please, join the calls. We hope to be done by november of this year with a brand new model states can use to update their procedures. If you want to be apart of that and know whats going on, jump on the calls. Wide love to have you. Thanks. Brian has agreed in the course of a q and a session. You now have a chance to join the conversation. Im going to exercise a little bit of prerogative to clarify things. At the appropriate time you can fill out a card thats in your pocket. You can also go to one of the microphones that are in the room. You can tweet a question using it the network so youve got all sorts of channels. What i want to do is a factual clarification. Weve heard a lot about in network and out of network. How many people dont know the difference between in network and out of network for purposes of this discussion. The question is is there a typical pricing pattern . In other words whats the penalty maybe not out of state being zero but in a typical plan if you are in a Narrow Network and have to go out for some reason or think you do, is there a substantial differential or is it fairly nominal . How important is this is what im asking . Dan, do you have any sense of that. Sure, again, i think its critical from the point of view providing value to consumers that we allow these High Value Networks to be a choice as many of you heard from a number of the speakers today many consumers are buying based on premiums. To get that down to an affordable rate. Its a choice there. If youre in a plan that does have a specific net whork then there are certain requirements to go outside that network. Plans say you cant do that but they will work with the individual on their specific needs. If theres a particular type of specialist that simply is not in the network and the plan has an on liging obligation to work with that customer to provide that medically necessary service. Part of it depends on the type of plan. If youre in an hmo that does not have out of Network Coverage than its far more restrictive than if youre in a hmo with point of Service Coverage but i think the differences are substantial. I think they have to be for the Narrow Network approach to work. Its not just that youll pay a higher coinsure fans rates but you wont be benefitting with the insurers negotiating ability if so youll be reliable for beyond what the insurer allows for in addition to the coinsh e coinsurance. The coinsurance counts but not what we call the balance billing. Okay. Do you want to identify yourself. Sure. My name is daniel davis. Im with the administration for Community Living in hhs. One of the considerations that were looking at quite a bit right now is the access to providers for people with disabilities in Narrow Networks. There are considerations where theres been a number of studies on subspecialties where theres 20 to 40 of providers according to secret shopper test that they dont serve mobile patient disabilities. To what extent do aic and the private Service Industry taking that into consideration and making saur there isnt inadvertent Health Discrimination . With the neic that is something that has been raised as an issue. Its something we need to look at. Its something that state regulators need to look at when they are reviewing the various plans. Not just that but especially with mental parity and things coming on. EnvironMental Health, et cetera. Theres a lot of issues that we need to take into consideration. We would agree. I would just add that networks very hard to comply with all the laws, rules, regulations. They submit their plans for review. They are approved in the state and if they are qualified they are approved by the federal government and are certified. They have to meet the standards set in leg rags to be able to meet the requirements. If you dont meet those youre not able to be in the market. Having the gentleman asking that question reminds me of a question that was submitted in advance that is related. It makes reference to the fact that the administration had communicated with plans not so long ago that they were going to focus on areas that have and the question actually votes historically raised Network Adequacy concerns including among others Mental Health providers. Do we have any elab rags of how the current discussions where the current controversies is for that matter deal with Behavioral Health issues. Kcatherine do you have anything to add on that. I would just add that clearly thats a consideration. We focus so much on first the what are the physicians and the hospitals in those networks. That becomes the bulk. As brian pointed out than you have the anesthesiologist. My point is theres also outpatient access that needs to be considered. Mental health. Home health. All of the care continuum for a network to be successful has to be considered. I absolutely agree with your point. Im dr. Caroline poplin im a primary care physician. I have two questions. One in the satisfaction surveys that i think you presented, did they break out people with chronic illnesses or people who have had a serious illness in the last year versus Healthy People paubecause most people a helmy most of the time. If people dont lose their network they will be received with. It sounds like each Insurance Company in an exchange are required to present a variety of plans maybe bronze, gold, platinum. People get very confused when they have too many choices. When they have five Insurance Companies offering 50 plans. Thats hard to deal with especially every year. In part d there was a study that most people didnt change their primary plan. They just kept the same plan year after year even though it wasnt the best plan for them. First on the Commonwealth Fund survey that i mentioned in my survey was very comprehensive. I dont have the actual data in front of me but if you go to the website you can see or whether it separated the specific operations because you will get a different answer from different people. That survey also included those that actually have used their plan too. Theres data on that as well. I encourage you to go to their website. It is very kprocomprehensive. With regard to your second question. Could you repeat that for me. Do you worry. About the fact that people are going to get confused having too many choices. Each one has a lot of information. Had the part d experience hasnt been all that reassuring on the question of whether can make a good choice. Thats a very good question. It really depends on the individual. Some are very savvy and sophisticated about looking through the websites and finding whats best for them. Thats why the aca provides more navigator assisters. You have broke trerz as well. Others that can help the individual review plans and make the joyce thats best for them and their families. Health plans are doing a will the too in terms of basic education to help individuals make the best choice including cost calculators are. If you know youre going to have a specific procedure what your outofpocket costs would be for that and the like. I think the structure of the offering defined by value probably helps consumers a lot going through this because i suspect that most consumers first decide what tier what medal they want to get so the number of plans arent as great. Actually wanted to followup a little bit. One of the questions that has been raised at least in the material its that have been given out. Presumably they arent two Different Things. There is a blend. There is a range of narrowness if you will. Are there some standard formulations that are being used either on the marketplace websites or among the plan its that can help people who dont deal with this kind of term innologist everyday to understand which of the choices they are making along that spukt rum. I can can answer that. In reading the mcenzie im thinking there is nothing like this out here. They came up with their own definitions whether it was ultranarrow or just. I probably it would be a good idea go forward in the same way that we have four medal tiers of plans to also they will be arbitrary but say that a kplan has below a certain plan of providers is called a Narrow Network plan. Consumers can put some aside. There wont be standardization but it would help the consumer simplify their search. Any talk about that . Tirks not at this time as far as nor model. As far as choices and information, i think states would like to look at. In the past weve seen carriers really try to hide things like that. They want information and distinguish between one plan and the other. How thats done and how clear it is, well work toward that. Its probably not something in our models specifically trying to standardize it in any way. Models do provide a standard benefit of coverage on healthcare. Gov. That provides Important Information to shop around. Theres other information on healthcare. Gov, new information will be coming in the future specifically with regard to quality and consumer satisfaction. Were currently building that in and working to produce that. You know, i think just with part d it will take a while for the Website Health care, healthcare. Gov can provide information that it needs to. I think in state based exchanges that states have tried to do too much and ran into some real challenges. A lesson learns there but plans are committed to providing the necessary information so consumers can make the best choice for their families. Lauren kennedy. My question flows nicely. Your last comments which is i wonder if any of the panelists can speak to what can be have been sub is hesful strategies specifically with regard to Quality Performance data. I think it was in everybodys presentation that this was a key criteria but also the consumers ability to access that informati