Contracting with QHPs in the Health Insurance Marketplace

May 13, 2013

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Marketplace Qualified Health Plans

Similar to Medicaid, the health insurance marketplace will have qualified health plans (QHPs)◦ Only QHPs will sell health insurance products

in the marketplace◦ QHPs will include a mix of regional, statewide

and multi-state products Health plans have/will apply to CMS and

the State to become a marketplace QHP in Michigan

QHP Benefits QHPs will be required to cover ten essential

health benefits (EHBs) in their products:1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services, including behavioral health

treatment6. Prescription drugs (at least one per therapeutic category) 7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic disease management10. Pediatric services, including oral and vision care

FQHC services are not specifically defined as an EHB, although may services we provide are included

QHP Benefits The essential health benefits were designed to

mimic a “typical employer plan” In every state, the rules define essential health

benefits based on a state-specific benchmark plan◦ In Michigan, the benchmark plan is Priority Health

HMO (with additions for pediatric dental and vision)

Limits have been placed on out-of-pocket costs and deductibles

Michigan EHB Benchmark- http://1.usa.gov/SDifE2EHB Fact Sheet- http://1.usa.gov/Xl4ocb

Medicaid Benefits- http://bit.ly/dpeGj8

Essential Community Provider (ECPs)

ECPs include FQHCs, Ryan White Providers, Title X Family Planning Providers, Indian Providers, Hospitals and Others

To become a marketplace QHP, health plans have to demonstrate their networks include essential community providers◦ Minimum Standard- 10% of available ECPs in the

plan’s service area participate in the issuer’s network◦ Safe Harbor Standard- 20% of available ECPs + All

Indian Providers and One ECP in Each Category in Each County

Marketplace QHPs in Michigan Plan to be a QHP and have approached Health Centers

already:◦ Molina Healthcare◦ Physicians Health Plan (PHP)◦ Blue Cross / Blue Care Network◦ Consumers Mutual Insurance of Michigan◦ Connection Dental ◦ Priority Health

Plan to be a QHP and have not approached Health Centers (that I know of):◦ Meridian Health Plan◦ Health Alliance Plan (HAP)◦ Delta Dental◦ United Healthcare◦ Aetna Who Else?

Strategic Considerations One potential QHP has agreed to pay Health

Centers PPS rates (so far) Others have provided an “opening offer” of 100%

Medicare fee schedule◦ Negotiate up from there!

Most plans are rushing to get contracts signed and shore up provider networks before month end

Most plans need ECPs (especially primary care) Think about what fair payment looks like for your

organization and how much you are willing to compromise

Think about the business opportunity in relation to your capacity and planned growth trajectory

Resources

MPCA Technical Assistance Resources Webpage

Our Presenter Today

Monica Powell-Gerald, MHSADirector, Innovative Care NetworksNational Association of Community Health Centers

Exchange Contracting Checklist OverviewMay 13, 2013

Monica Powell-Gerald, MHSADirector, Innovative Care Networks

PCA/Network Relations mpgerald@nachc.com

Exchange Contracting with a Previously Contracted Insurer/Issuer

• Be cognizant of the fact the each Agreement/Amendment builds upon the other

• Pay attention to new terms that are introduced via the proposed amendment

• Issuer may “delete and replace” language using the Amendment which may negate any previously negotiated language

• Amendment may alter other contract provisions or previously negotiated fee schedules

New Agreements with QHP Issuers

• Become familiar with the contract documents

• Make certain that the roles and responsibilities of both the CHC and the Issuer are clearly defined by the proposed Agreement

• Closely examine provisions related to new product introductions and contractual amendments

• Review Utilization Management Guidelines

• Conduct a in depth review of Issuer policy and procedure manuals

State and Federal Regulations

• Become familiar with references to state and federal laws and regulations found in the proposed agreement

• Gain familiarity with recent federal guidance related to QHP network development, structure, function and monitoring

• Become knowledgeable of payment requirements for exchange products

Review ALL Associated Contract Documents

Common Contract Documents Include:

• Fee Schedules

• Utilization Management Program Guidelines

• Policy and Procedure Manuals

• State Regulatory Attachments

CHC and Issuer Responsibilities

Contract should clearly define the responsibilities of CHC and Issuer/Insurer

• Scope of Services Provided

• Credentialing

• Claims Submission and Payment

• Payment disputes and overpayments

• Amendment Process

Negotiating A Competitive Fee Schedule

• Conduct a complete review of the proposed fee schedule in conjunction with CHC CFO

• Compare your current PPS rate to those rates proposed by the Issuer/Insurer

• Request a sample fee schedule from the Issuer/Insurer (generally the top 20 most commonly billed codes)

• Utilize the fee schedule carve-out mechanism to establish fees for services that are substantially undervalued by Issuer/Insurer

Contractual Updates and Policy Modifications

• Include language that requires 30-45 days prior written notice for updates to policy and procedures and other contractual modifications

• Propose language that gives your organization 30 days to respond to any proposed contractual modifications or amendments

• Protect your organization from the introduction of new products that may have alternative fee schedules by requiring notification of and a 30 day review period to respond to the proposed changes

Term and Termination Provisions

• Set contract term limits that minimize your risk

• Should you decide to terminate the agreement set a reasonable notification timeframe

• Examine closely the reasons that the Issuer/Insurer can terminate the agreement, if possible, make these provisions mutual

• Review termination provisions with legal counsel

Outline Eligibility Verification Mechanism within the

Document

• Can eligibility information be verified 24/7?

• Is eligibility information available real-time?

• How frequently are Issuer eligibility files updated?

• How should provider handle claims that are denied due to erroneous eligibility?

Non Payment of Member Premium

• Address how payments for denied claims are handled in instances where premium remains unpaid following the expiration of the 90-day grace period

• Identify the party responsible for the payment of claims

• Identify the process to follow for reprocessing and paying these claims (re-submission or special project)

• Outline the timeframe for initiating and completing this activity

Questions?????

For More Information Contact:

Monica Powell-Gerald, MHSADirector, Innovative Care NetworksNational Association of Community Health CentersEmail: mpgerald@nachc.com