PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014

P R O V I D I N G P O W E R F U L S O L U T I O N S

Selecting a PROVEN Network Adequacy Model for Your State

Welcome

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014

P R O V I D I N G P O W E R F U L S O L U T I O N S

Robert Smith, Regional Sales Director

AGENDA Evolution of Network Adequacy

From Access to Adequacy

Creating Standards

Publish the Process

Current process for verifying Network Adequacy at the Federal Level

Early Adopters who have Vetted the Process

The History of Access

Early Challenges

Single Measurement All areas/counties measured the same 1 in 30 miles

Regulations Designed on Convenience To avoid dozens of maps PCPs, Hospitals & Specialties in aggregate Consumer protections put off

Early Challenges

Vetting of the Standards Standards often were not even attainable Do providers even exist in the market?

Resulted in an exception process More manual reviews

Process Dictated Frequency One-time or maybe annual More reviews meant more cost

Network Adequacy Design Rules

Address Geographic Disparities

Prevent Adverse Selection

Monitor Narrow Network Concerns

Automated Review

Flexible for Various Programs

Scalable with Directory Requirement

Addressing Geographic Disparities

Federal County Classifications

Addressing Geographic Disparities Oregon County Classifications

Large Metro Metro Micro Rural CEAC

Preventing Adverse Selection

Federal Specialty Types

Individual Provider (MD/DO) Specialty Types Facility, Pharmacy, and Other Non-MD/DO Specialty Types

001 General Practice Pharmacy 002 Family Medicine 040 General Acute Care Hospital 003 Internal Medicine 041 Cardiac Surgery Program 004 Geriatrics 042 Cardiac Catheterization Services 005 Primary Care – Physician Assistant 043 Critical Care Services - Intensive Care Units (ICU) 006 Primary Care – Nurse Practitioner 044 Outpatient Dialysis 007 Allergy and Immunology 045 Surgical Services (Ambulatory Surgical Centers and Outpatient Hospital) 008 Cardiovascular Disease 046 Skilled Nursing Facilities 010 Chiropracty 047 Diagnostic Radiology (free-standing; hospital outpatient; ambulatory health facilities with Dx Radiology) 011 Dermatology 048 Mammography

012 Endocrinology 049 Physical Therapy (individual physical therapists providing care in Free-standing; hospital outpatient and ambulatory health care facilities)

013 ENT/Otolaryngology 050 Occupational Therapist 014 Gastroenterology 051 Speech Therapy 015 General Surgery 052 Inpatient Psychiatry (Free-standing inpatient psychiatric facility and psychiatric beds within an Acute Care Hospital) 016 Gynecology (OB/GYN) 054 Orthotics and Prosthetics 017 Infectious Diseases 055 Home Health 018 Nephrology 056 Durable Medical Equipment 019 Neurology 057 Ambulatory Health Care Facilities - Infusion Therapy/Oncology/Radiology 020 Neurological Surgery 061 Heart Transplant Program 021 Medical Oncology & Surgical Oncology 062 Heart/Lung Transplant Program 022 Radiation Oncology 064 Kidney Transplant Program 023 Ophthalmology 065 Liver Transplant Program 025 Orthopedic Surgery 066 Lung Transplant Program 026 Physical Medicine & Rehabilitation 067 Pancreas Transplant Program 027 Plastic Surgery 000 OTHER 028 Podiatry 029 Psychiatry 030 Pulmonology 031 Rheumatology 033 Urology 034 Vascular Surgery 035 Cardiothoracic Surgery 101 Pediatrics - Routine/Primary Care 102 Licensed Clinical Social Workers 103 Psychology 000 OTHER Dental - General Dental - Orthodontist Dental - Periodontist Dental - Endodontist

From Access to Adequacy

Minimum number of providers • Must contract with sufficient numbers of

each specialty type

Maximum Travel Time & Distance to Providers/Facilities • 90% of beneficiaries have access to

providers within the standard

Beneficiary File

Updated Annually

Representative of the Population Distribution

Same File for Part C and Part D

Everyone Measured Against the Same File

CMS Standards

CMS Standards

Scalable

What if the directory data can feed the network adequacy review? Reduces burden on issuers Eliminates inconsistencies Scalable as requirements change Reviews can be as frequent as directory updates

Federal Data Format

CCIIO Network Adequacy Data Template National Provider Number (NPI)*

First Name of Provider*

Last Name of

Provider*

Physician / Non-

Physician*

Specialty Type

(area of medicine)*

Street Address*

City* State* County* Zip* Network IDs*

CMS Provider Data Template

SSA State/ County Code

Name of

Physician or Mid-Level

Practitioner

National Provider Identifier (NPI)

Number

Specialty

Specialty Code

Contract Type

Provider Street Address

Provider City

Provider State

Provider Zip Code

Provider

Previously

Listed? (Y or N)

If PCP, Accepts

New Patients? (Y or

N)

Name of

Medical Group Affiliation or "DC"

Employment Status

Uses CMS MA

Contract

Amendment (Y

or N)

Provider Tables

SSA State/County Name of Physician or Mid-Level National Provider Identifier Specialty Specialty Code Contract Type Provider Street Address Provider City Provider SProvider Z Provider Previously Lis 52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 N52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52320 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52320 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52390 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52390 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y

MA PROVIDER TABLES

MA Provider & Facility tables with all the providers in your data that fall under the criteria for the reporting county

(whether they are in the county or not). All Health Plans Must POPULATE the county codes, servicing providers, specialty crosswalk and previously listed.

TXT format is required when submitting to the HPMS site

All Health Plans submit data in the exact same format

Automated Review

Additional Reporting Options…

Network Adequacy Review

NPI Validation

Specialty Validation

Validation of Utilization

Trend Analysis

Market Availability

Plan Comparisons

State & Federal Level Automation

CMS Part C and D

CMS Dual Eligible MMP

CCIIO FFM Exchanges

State of California (DMHC)

State of Florida (AHCA)

Recap of Process

Publish the Process and Standards Beneficiary File used for all plans Time and Distance standards with Minimum Servicing Providers

Upload HSD Provider Table in Consistent format

Specialties “not met” Notices sent to Health Plans

Minimizes burden to issuer

Eliminates manual reviews for regulators

Provides effective consumer protections

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014

P R O V I D I N G P O W E R F U L S O L U T I O N S

Robert Smith, Regional Sales Director